"The Ronan Report" provides insight about the activities at the Western Maryland Health System in Cumberland, Maryland, and about the changes taking place in healthcare today from a CEO's perspective.

Friday, January 30, 2015

Turning Bad into Good

This morning, I read Paul Levy's blog (Not Running A Hospital) regarding a new health care task force consisting of hospitals, physicians, employers and payors that has committed to shift 75% of its members to value-based care delivery by 2020. Really? How progressive. Do you think that you have given yourselves enough cushion with five years?  That story is for another day.  The title of Paul's blog was "Marching but where? Moscow, I fear" and the graphic was a depiction of Napoleon's disastrous march on Moscow.   The graphic served as an immediate reminder of a time at WMHS that many could easily want to forget.

A number of years ago during the early stages of the affiliation of Memorial Hospital and Sacred Heart Hospital to form the Western Maryland Health System, we engaged an architectural firm to assist with our master facility plan.  As some will remember, the many scenarios that were created included such things as build a “new” Memorial at Scared Heart, Sacred Heart as an inpatient hospital and Memorial as an outpatient hospital or the division of clinical services between the hospitals, which we ended up with at the end of the day.  The interesting part was during one of his many presentations, our architect presented a depiction of Napoleon's March on Moscow in 1812 to show how we could depict the various factors at work with our project.  Napoleon's March depiction (shown below) graphs the number of troops at each position, their location by date and the temperature at any given time during their march.  This depiction is probably the best statistical graphic ever drawn and our architect tried to use it to describe our project.  After his presentation, I got a closer look at the depiction and I too was enamored with the graph.  However, I pointed out to our architect that while the depiction was powerful, what it was describing was an unmitigated disaster for Napoleon.  He lost over 400,000 men and he was chased out of Russia suffering one of the greatest defeats in history.  This defeat led to Napoleon's downfall as a world leader and began Russia's dominance as a world power.  

At the time, little did I realize as to how accurate that depiction was to our situation that was soon to evolve.  Now, I am not trying to compare Napoleon's defeat to the early years of our affiliation but, quite honestly, the message was there and at the time everyone laughed it off.  Those early years were difficult and challenging; some days were downright horrible.  However, what has become of the Western Maryland Health System has been amazing and would not have happened without those many early challenges.  Unlike Napoleon, it was well worth for us.

Wednesday, January 28, 2015

OK So Which Is It? Are ED Visits Increasing or Decreasing?

Over the last two days, I have read two articles on ED Visits.  One article was in Modern Healthcare and the second was in a Pittsburgh newspaper.  Modern Healthcare is stating that ED visits are increasing nationwide as more people are eligible for care under the Affordable Care Act, but they still wait until they are really sick to seek care.  

The second article says that patient navigators are being especially effective in directing patients to the most appropriate care.  In western Pennsylvania, there was a study of the effectiveness of patient navigators funded by Highmark and, not only was there a decrease in ED visits, but also in admissions and readmissions.  The navigators were able to direct patients to access care more efficiently.  That doesn't seem to be the case for the busiest EDs around the country.  They are seeing increases due to patients who are now covered, physicians closings practices and other practices no longer taking Medicare or Medicaid patients.  

This is an interesting dichotomy, in that we have had the experience that is more like western PA, at least up until the current flu season.  If you take time to understand the changes needed for the successful delivery of value-based care, such as increasing primary care centers, dedicating patient navigators like the Pennsylvania study did, adding community health workers, expanding home care, growing hospital medicine programs to better accommodate physicians who want to focus on an office practice exclusively, identifying and caring for your high utilizers in a settings that is outside of acute care and the list goes on.  Until all hospitals are focused on transitioning away from volume-based care to value-based care, the busiest EDs are going to continue to experience this.  It is also important to note that these initiatives take time to really see a difference.  
At WMHS, in a little more than a year, we have saved $4.5 million with our high utilizers alone through our Center for Clinical Resources through a reduction in admissions, readmissions, non-emergent use of the ED, less ancillary testing and by providing more directed care in the most appropriate location.

Friday, January 23, 2015

Connecting with Our Community

An article crossed my desk this afternoon and I found the title to be very interesting. Hospitals and Community Health - Hospitals Partner with Local Organizations to Promote Healthy Lifestyles.  I enjoy reading articles that are going to provide new ideas for better connecting with our community, especially those with the greatest needs.  

The article used three examples of partnerships between hospitals and their respective communities. The first was a hospital providing scholarships in its community.  A great idea; we have been providing allied health profession scholarships as long as I can remember.  

The second example was a hospital providing a mobile garden of fresh vegetables in its at risk communities.  We are embarking on a community garden concept and it will be operational by this Spring.  We have held a Farmer's Market at WMHS for the last several years and recognize its success.  We wanted our most vulnerable patients and community members to have that same advantage of fresh vegetables being provided to them.  Through this initiative, there have been a host of partnerships that have evolved to ensure the program's success. Possibly, it will evolve into something much more after we get our first community garden going and just maybe we'll go mobile.  

The third example was a Raising Readers program where physicians and nurses provide books to children at the time of their birth and throughout their well child visits.  Each child receives 12 books by the time that they go to kindergarten.  A great program, but one that pales by comparison to WMHS.  At WMHS, we enroll every newborn in the Imagination Library.  Every child receives a book each month until they go off to kindergarten.  That's 60 books!  

I guess that we are going to have to start providing our successes to the American Hospital Association's Advancing Health in American website.  But, it was great to read about these programs and use it as an affirmation of what we are doing for our community in Cumberland.

Wednesday, January 21, 2015

Maryland Health Resources Commission

Last year, I was appointed by the Governor to the Maryland Health Resources Commission.  Yesterday was only my second in-person meeting, but I really enjoy being a part of this Commission.  This Commission is only one of three health care commissions in Maryland and it was created almost ten years ago to expand access to affordable quality health care services to the state's underserved communities.  I am the only health system CEO on the Commission so I am able to bring a different perspective to the group.  

During yesterday's Commission meeting, a white paper was presented on Sustaining Community Hospital Partnerships to Improve Population Health; and of course I had a lot to say.  The white paper was very well done by Fran Phillips, RN and included a number of recommendations on how to promote sustainability of Maryland's safety net providers to deliver health care services to our most vulnerable citizens.  

Some of the recommendations for the Commission were as follows: collaborate better with Maryland hospitals as they develop value-based strategies to keep patients healthy and out of the hospital; partner with hospitals on the savings that they will generate through reduced admissions, re-admissions, ED visits and reduced ancillary utilization; better coordinate with hospitals grants that are being requested by individual health care partners; promote promising hospital community partnerships around the state; encourage multi-investor partnerships to jointly fund projects of mutual interest; better link grant applicants with funding opportunities in addition to Commission grants as they become available; partner with Medicaid to jointly evaluate outcomes of partnership grants to reduce spending and improve Medicaid enrollee's health and work with hospitals to leverage Community Benefit dollars in areas with the greatest need.


I am pleased with the contents of this white paper as it attempts to better coordinate the spending of scare resources as the Commission attempts to meet its charter and hospitals attempt to meet their respective missions in the communities that they serve.

Friday, January 16, 2015

American Hospital Association Meeting

Yesterday, I was honored to speak at the American Hospital Association's State Issues Forum Meeting.  It was a meeting of State, Regional and Metropolitan Hospital Association Executives in Washington, DC.  I was invited to speak on the Possibilities and Limitations of Provider Payment Reform, specifically the Western Maryland Health System's journey related to value-based care delivery.  In addition to describing our journey, I was able to address questions related to work force, the challenges that we faced, the lessons learned, why we chose to pursue value based care delivery when no one else was, how the concept was financed, how the model is sustainable and how did we meet the needs of the behavioral health patients who also have general acute care needs.


The presentation was well received with a number of follow up requests to speak at the individual state association meetings.   All is all, a very rewarding day.

Tuesday, January 13, 2015

Weighing in on Emerging Health Care Trends for 2015

Fierce Healthcare, a national health care newsletter, contacted me last week for a piece that they were doing related to emerging health care trends for this year.  I was honored to be included and attached is the finished product.

















For the whole article, click here

Monday, January 12, 2015

America's Bitter Pill

Last night as the 60 Minutes segment on health care started, my iPhone lit up with messages about getting my thoughts on the content.  That was easy; first, Steven Brill has little credibility with the misinformation and inaccuracies that appeared in his Time article about  two years ago.  Lucky for us, he is now shilling his new book with a similar title as the article, America's Bitter Pill.  

He needed to quickly hurry up and get the book released because, in the short term, it will be more useless than it is now.  Health care is changing as demonstrated by what health systems such as ours have been doing for the last four years.  Our focus has been on value-based care delivery, not generating as many tests, procedures, surgeries, admissions and ED visits as possible.  Volume-based care paid on a fee-for-service basis is quickly being replaced with incentivizing hospitals for keeping people healthy and out of the hospital.  America will start to see a sea change in the short term related to care delivery.  Everyone recognizes that spending almost $3 trillion on health care in the US annually is unsustainable, so new approaches like Maryland's Total Patient Revenue and Global Budget Revenue will be popping up all over the country.


As for 60 Minutes, I received information last week from the American Hospital Association on last night's segment.  AHA was asked to make someone available to be interviewed for the segment.  AHA in turn asked for a copy of the book since they took great exception to his Time article again due to misinformation and inaccuracies.  60 Minutes refused. AHA said in order to respond to charges made by Mr. Brill, having an idea of what was in the book critical of hospitals would have been helpful.  As a result, they declined.  

Using the Institute for Health Care Improvement's Triple Aim of Health Care reform (better care; healthier communities and reducing the cost of care), as well as the related components of the Affordable Care Act, hospitals across the country are focused on building healthier communities. Mr. Brill in his book glosses over what hospitals do each day in the care of our patients as did 60 Minutes.  They love to focus on the negatives that are quickly being addressed and eliminated as Jeffrey Romoff, the CEO of UPMC, stated during the segment.  

Mr. Romoff agreed to be interviewed for the segment since he, UPMC and his salary have been targets of Mr. Brill's since the Time article came out in 2013.  I thought that Mr. Romoff held his own during the segment and, quite honestly, he is the CEO of the largest non-government employer in Pennsylvania with 62,000 employees and almost $12 billion in revenues.  Mr. Brill likes to equate not-for-profit health care with your typical not-for-profit organization and that is not a fair comparison.  Health care is big business and, in UPMC's case, it's very big business.  Quite frankly, they do it well.  They are ranked 12th as one of America's top health systems.   

Hospitals continue to be an easy target for the likes of Mr. Brill and 60 Minutes; however, they had better get their licks in quickly because changes are a comin'.  Stay tuned.

Thursday, January 8, 2015

It's Taken This Many Days to Get Over the Loss

I had the opportunity to attend the Steelers / Ravens game on Saturday night.  Now that's a day in my life that I will never get back.  Not only was the trip to Pittsburgh treacherous with ice, freezing rain then excessive amounts of rain and fog, but to have a group of loosely termed "professional" athletes perform as abysmally as the Steelers did last week, the weekend fell into the category of "why did I bother."  

I have never seen a football team more ill prepared for a game than the Steelers were on Saturday.  The defense was outplayed on almost every down, especially the long third downs when the Ravens completed almost every one that they had.  The offense clearly missed  one of the NFL's leading rushers in Le' Veon Bell, but that still wouldn't have been enough.  The offensive line couldn't protect Ben Rothlisberger and Ben chose not to throw the ball down field against the league's worst secondary.  Dri Archer became the go-to guy out of the Steelers backfield, all 5'7", 135 pounds of him (and he was stopped every time).  They resorted to the lousy Steelers from earlier in the season with stupid penalties and poor decisions on special teams.  

Baltimore came to play.  They were well disciplined and exceedingly well coached.  The Steelers had apparently been reading their press clippings for the week leading up to the playoff game instead of practicing and establishing an effective game plan. Congratulations to the Ravens; they deserved this victory.  I know that I have taken the fun out of the ability of the Ravens' fans to give me a hard time, but when your team dominates my team as the Ravens did on Saturday, you deserve to hear all of the platitudes directly from me.  

Now, there was a bright spot for humanity on Saturday evening, but it may fall into the category of too much information.  A number of rows in front of me were six Ravens' fans sitting together.  From when they arrived in their seats, they started talking trash.  None of it was in fun; these guys were thug like; both mean and looking for trouble.  My guess was that they were members of some gang.  They were  pushing  and shoving  fans  in the stands  without any regard for being outnumbered a zillion to one.


Right before the half, I went to the restroom.  The lines were long, but I still waited in line.  Behind me in line was a Steelers' fan who was trashing talk about Baltimore.  Lo and behold, who comes into the restroom, but the six gang bangers and that's when the "fun" began.  They start telling everyone in the bathroom what we could do to our mothers and what acts we could all perform on them. (Use your imagination.)  It was wild and began to escalate quickly.  The pushing and shoving started between the Pittsburgh trash talker and one of the gang bangers.  

Now for the humanity bright spot.  Three Steelers' fans immediately stepped between them and told the obnoxious Steelers' fan to leave the restroom.  They said get out and go use another bathroom.  Fortunately, he did and the situation immediately de-escalated.  This situation could have been really ugly.  A couple of hundred drunk Steelers' fans and six thugs who could have been carrying weapons of any sort.  I say that because the new security wanding process to get into the game was laughable.  There was some kid with "Security" on his jacket waving a wand in front of me with my pockets filled with an iPhone, keys, change, wallet; heck I could have had a rocket launcher strapped to my back and he would have missed it.  That wand or any wand never made a sound; some high intensity NFL security that they had there.  

Anyway, it was both a night to forget (the game) and a night to remember (the very impressive de-escalation of what could have been a really bad situation).  So, now I have to wait until next year to resume my fair weather fan status, but at least next season, I have significant justification.

Wednesday, January 7, 2015

89 New Accountable Care Organizations

I was reading Sean Cavanaugh's blog the other day.  Sean was formerly with Maryland's Health Services Cost Review Commission and now is the Deputy Administrator and Director for the Center for Medicare.  His blog was announcing the 89 new Accountable Care Organizations (ACOs) that joined the Medicare Shared Savings Program.  The new ACOs in the CMS program now bring the total to 405, serving close to 8 million Medicare beneficiaries.  

We are one of the new ACOs, the Western Maryland Physician Network LLC.  Together with physicians and other providers, we are focusing on providing higher quality, coordinated care for patients in the Medicare program.  We have almost 6000 Medicare beneficiaries that our ACO is serving and we hope to deliver better care consistent with our new care delivery model that is based on providing value, reducing the cost of care and ensuring that our community is healthier as a result.  All of which are consistent with the Triple Aim of Healthcare Reform.  

This partnership with our physicians and advanced practice professionals is great progress as we are continually exploring new and better ways to deliver care to our community.

Monday, January 5, 2015

Hospital Patients are Watching and Listening

Over the holidays, I had the opportunity to spend a lot of time with my daughter Jessica and her husband Terrell, who is a very recent cancer survivor.  Anyone who has read my blogs since last February knows of the challenges that these two individuals have gone through.  I have blogged that they became my heroes after what they have endured.  My hero worshipping continues.  

Over breakfast one day last week, we were talking about Terrell returning to his job today on a full-time basis.  I asked if he was ready for all of the challenges that he would face on his first day back to work at Pulte Homes. (By the way, a wonderful company to work for in how they treated Terrell during his nine-month battle with cancer last year).  He said that he was, but that he would be approaching his job very differently this time around.  

After spending well over 100 days hospitalized receiving chemotherapy and having his knee and partial femur replaced as a result of the cancer, he made a very valuable observation during his many hospitalizations. He realized that he had an expectation to be cared for in the most effective and efficient way possible.  His caregivers recognized that and they managed his expectations, but they also did everything possible to meet his needs, requests and demands as a patient.  

He learned that same thinking can be translated to his position as a project manager for a new housing development in Charleston, SC.  His new homeowners have an expectation to have a "perfect" home built for them.  Previously, he felt that these new homeowners were being overly demanding and unrealistic.  He has since realized that no one was managing their expectations and that they have every right to expect a perfect home.  Starting today, the new approach to his job will be to deliver the best possible new home to each new homeowner and, if something isn't right, to make every effort to ensure that it is right.

Pamela said that my face lit up, as I could immediately identify with Terrell's new approach to customer service.  Many years ago when I was Director of Materials Management in a large teaching hospital, I needed an attitude adjustment.  I felt that nursing was taking advantage of my employees with their demands and that they were not carrying out their duties and responsibilities as it related to interactions with my departments.  Then, my office was temporarily re-located to a patient unit while construction of my new office occurred.  It turned out to be a few of the best months of my professional life.  I quickly realized that there were unbelievable demands that were being placed on nursing by patients, family members, physicians and their leadership; many of which were unrealistic with no recognition of that fact.  The staff nurses were being pulled in every direction and orders were written with the expectation that they were filled immediately.  The entire experience was a learning revelation for me and just as quickly for my staff.  I immediately changed our approach in working with nursing.  I took members of my leadership team on rounds and walked them through why our role was changing.  I showed them why we were there to now serve nursing as they cared for our patients.  My staff got it pretty quickly and I become beloved by nursing.  


As Terrell returns to work today, he will be asking if he can lead an inservice for his division's employees on what it takes to be truly customer service focused.  Awesome and because of what he experienced as a patient in seeing how important service engagement can really be, his company and homeowners will be very well served as a result.