"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, July 20, 2018

One of the Greatest Transformations for Hospitals: Value-Based Care



BR:  Since 1980, the healthcare environment has been reshaping itself. Today, there are 1400 less hospitals and yet a 40 percent increase in population. In 2010, Western Maryland Health System (WMHS) could see this change and implemented a value-based care model within our system. We transitioned our workforce to shift the delivery of care away from volume-based care to value-based by moving care across the care continuum and to provide care in the most appropriate location. Value-based care is considered to be the future of healthcare with a focus on helping patients improve their health and well-being through a shift on health emphasis and resources. This care model engages healthcare providers to reduce admissions and readmissions; strengthen patient engagement; reduce variation in quality; work collaboratively with community partners; reduce utilization of the emergency department (ED) as well as observation and ancillary services while saving millions of dollars. This approach measures health outcomes against the cost of delivering those outcomes.

BR:  While implementing the value-based model at WMHS, we found that a critical component of keeping patients healthy and out of the hospital that still needed to be addressed were the social determinants of health. After a careful analysis, issues affecting the patient’s health outcome were the result of poverty, food insecurity, heart disease, chronic obstructive pulmonary disease, diabetes, access to care and substance abuse. We started to look at the whole person more carefully and the needs surrounding them.  From job opportunities to primary care “hot spot” clinics to community gardens, patients now have resources to address not only their physical health but the social triggers that may affect their health outcomes.

By building a culture of health and collaborating to address the social determinants of health, we have dramatically reduced the cost of care over the last eight years by tens of millions of dollars, improved the health status of our community in a number of areas, improved our regional health rankings in key focus areas, and truly made a difference in the lives of many of our patients and residents throughout the region.

BR: WMHS has established many safety net partnerships throughout the region with pharmacies, the local health department, social service agencies, the business community, the food bank, the Boards of Education, Chambers of Commerce, City and County governments, and our colleges and universities. By collaborating with community partners, we are working to build a culture of health and provide comprehensive care to our community and the surrounding region. Through this culture of health, WMHS has seen a decline of 27 percent in admissions, 25 percent in readmissions and 15 percent in emergency room visits through these initiatives. One such initiative is Bridges to Opportunity, this is a program that provides community leadership to bring people out of poverty. We have also implemented a focus on food insecurity throughout the community that is delivered through education around healthy eating, school exercise programs and participating in several feeding programs for children and the community at large. Through our community partners, we have gone even further by establishing seven community gardens and an orchard to ensure fresh fruits and vegetables are available in the surrounding food desert locations. To deliver accessible comprehensive care to the community, WMHS is providing primary care clinics or “hot spot” clinics in homeless shelters, churches, senior centers and even, municipal buildings. There are many health concerns facing our community, but by creating many community partnerships, we are very well positioned to address those concerns now and into the future. When delivering the value-based care model and the initiatives surrounding population health, it is necessary to respond to the needs of the community.

Friday, June 29, 2018

How is WMHS Meeting the Many Challenges in Healthcare?

The healthcare field is certainly changing and if Western Maryland Health System isn’t keeping up with the changes, we could end up like one of the 89 hospitals that closed in 2017 with the majority being in rural areas. It has become apparent that because of our remoteness and economic development challenges, it is more difficult to bring physicians, primarily specialists and sub-specialists to our area. As a result, we have signed a clinical affiliation agreement with University of Pittsburgh Medical Center. They will assist us with such clinical needs as Vascular Surgery, Thoracic Surgery and coverage for Dr. Mark Nelson and the Cardiac Services program, as well as Oncology and Behavioral Health. We will continue to explore other ways in which UPMC can assist with the many challenges we face every day. Fortunately, we do have a lot still going for us. We benefit greatly from the Maryland Waiver which brings an additional $2.6 billion to the state provided we continue to meet a series of benchmarks related to improved quality, reduced utilization and cost savings. We transitioned healthcare delivery in Maryland eight years ago from a system based on volume to one that is value based. That transition brought us a great deal of advantage as it allowed us to demonstrate our commitment of placing the patient first in the care delivery system. We’ve been able to achieve remarkable partnerships across the care continuum to ensure patients receive the care they need where they need it. These partnerships have helped reduce the gaps in care and have better addressed the needs of the most vulnerable. We are much further ahead of other hospitals, in other states, with our care delivery model and our efforts in reducing the cost of care. We now care for patients in the most appropriate location including throughout the community and within the home.


As we attempt to work through the many changes, challenges and disruptions facing our industry, our goal at WMHS is to not only sustain healthcare services in western Maryland, but to enhance those services. Building upon the newly created relationship with UPMC could take us to long term viability through cutting edge technology, innovative programs and services as well as access to the many other clinical programs offered by one of the largest health systems in the United States. Most importantly, UPMC wants to offer those services in our community to the extent possible and not have the patient travel to Pittsburgh or Altoona unless it is absolutely necessary. This relationship with UPMC is an excellent next step for WMHS as we not only attempt to improve our viability but, with all of the difficulties that we face, our long-term survivability.

Thursday, June 21, 2018

THE PEDIATRIC UNIT AT WMHS IS NOT CLOSING


If there was ever a time to re-engage my blog, now is it.

Since early June, I have been reading and hearing so much misinformation regarding the WMHS Pediatric Unit.  We are NOT abandoning children by closing our Pediatrics Unit.  The term “closing” is a regulatory term that we have to use even if we are transitioning our unit from virtually a single Pediatric inpatient bed on an adult patient unit to a five bed Pediatric Observation Unit adjacent to the Emergency Department.  Unfortunately, last Saturday’s newspaper headline stated that the unit was closing.  If you just read the headline and not the article, I can see how one would think that the Pediatric unit was actually closing, but again, that is not the case.

Beginning in early August 2018, any child requiring an overnight stay will be cared for in a dedicated, secure unit that is being newly constructed next to the ED.  The child can remain in the unit up to 48 hours; after that, clinical decisions will be made as to transfer or discharge to home.  This unit will be staffed by Pediatric Advanced Life Support trained nurses along with Emergency Department physicians and physician assistants.  Pediatricians will continue to attend to children in the unit, as well.  Because we have so few pediatric patients (for the first nine months of the fiscal year, we have admitted 44 children who have stayed an average of 1.93 days), our Pediatric staff nurses cannot maintain their expertise, nor can we recruit dedicated Pediatric nurses because we admit so few children.  The ED staff are very well trained in caring for and treating both adults and children.  In fact, last year we treated close to 9,500 Pediatric patients in the Emergency Department with 86 being admitted to WMHS and about 300 being transferred to a Pediatric Specialty hospital due to their chronic or critical condition.  As a parent and a grandparent, I can’t imagine why a parent or guardian wouldn’t want their very ill child treated in a specialty facility where the specialists treat thousands of children each year. 

Some have said just bring the specialists to Cumberland and we do, but caring for children on an outpatient basis usually for chronic or follow up care in Pediatric Cardiology and Neurology.  With a two hour travel distance and so few patients, it is unrealistic to think that specialists would come to Cumberland to perform surgery on one child.  There are physician shortages in virtually every specialty for both adults and children and areas such as ours have the greatest challenges in recruiting.  WMHS like so many other community hospitals have had to resort to alternatives in the care and treatment of children.  We are using more digital technology, telemedicine, and partnerships to address the needs of children and through our affiliation with UPMC, these advancements will continue to grow.  In Maryland, 33 out of the 47 hospitals, have Pediatric Units.  Eighteen of those hospitals have a length of stay for Pediatrics of less than a day and there are nine Maryland hospitals similar to WMHS with a length of stay of less than two days.  Over the last 30 years, Pediatric beds in Maryland have decreased by more than half from 882 to 385.  More and more children are being cared for in the most appropriate location, a specialty hospital, when they have a critical or chronic condition.

I certainly recognize the hardship for families who have to travel out of the area if their child is very ill.  Our staff at WMHS will work with the specialty hospital as well as throughout our community to assist with this hardship to the extent possible.  Although such transfers have been occurring for the last several years, we will become more engaged in the process and assist these families in navigating the challenges that they face when such circumstances arise.

I hope that the information contained within this blog helps to clarify the circumstances surrounding Pediatrics at WMHS.

Thursday, June 8, 2017

Insurers and ED Visits

I can’t tell you how many people sent me the article last week regarding Blue Cross and Blue Shield of Georgia stopping coverage for ED visits that they deem unnecessary.  I am not sure as to all of the fuss since insurers serving their members in western Maryland have been denying payment for what they deem unnecessary care for the last several years.  If BC /BS of Georgia is like our local insurers, they will do little to nothing to educate their members on when and when not to use the ED, but hold the hospital accountable for the care that it rendered to their member.  

When a patient presents in the ED, we are required by law to provide care.  We have been working to educate patients on when to use their physician versus urgent care versus the ED.  We have had some success over the last few years, but we still have to fight denials on a continual basis.  We have increased visits to urgent care while reducing the number of ED visits; but again, that responsibility has fallen to the hospital.  We can’t be providing expensive emergency level care knowing that we won’t be paid.  

I certainly do not begrudge insurers seeking to reduce their costs, but their solutions need to be well thought out and applied as such.  Simply removing the proverbial monkey from their back and placing on the back of the hospital isn’t a viable solution.

Friday, May 12, 2017

Reducing Healthcare Spending While Preserving Jobs

As you may know, I am a contributor to FierceHealthcare's Hospital Impact, an online publication that is a peer-to-peer forum for hospital executives, physicians, and other hospital leaders that addresses clinical and operational issues.  

Below is my latest post about the challenges involved with addressing healthcare spending while preserving jobs in the community.


FierceHealthcare




Thursday, March 30, 2017

Status of Clinical Affiliation with UPMC

In an effort to keep everyone informed as to the progress that we are making in our discussions and negotiations with UPMC on our clinical affiliation, let me offer the following:
The discussions for a clinical affiliation with UPMC are progressing well.  The next step is finalizing the letter of intent, which summarizes the contractual agreement between WMHS and UPMC.  We anticipate that this letter should be signed in the next few weeks. Once the letter of intent is signed, we will negotiate the definitive agreement, which specifies the details for the clinical affiliation between WMHS and UPMC.

The following areas have been identified as part of the first phase of the clinical affiliation:  vascular surgery, thoracic surgery, cardiac surgery, neurosurgery, medical oncology, and behavioral health. We have established clinical services work groups for these areas, and we are in the process of identifying dates for a series of site visits by UPMC’s clinical leadership in theses areas.

Kim Repac, WMHS CFO, is in Pittsburgh today giving a presentation to UPMC leadership and staff on the Maryland Rate Regulation System.  Since our affiliation is their first in Maryland, they would like to have a better understanding of our rate system and our current payment model.

UPMC leadership will be presenting at the WMHS board meeting in April as to their plans for our affiliation and also will provide an update on other affiliation activity currently underway within their system.

Last Friday, I had the opportunity to meet and spend some time with six hospital CEOs from throughout Pennsylvania whose hospitals all have a clinical affiliation with UPMC in some form.  To a person, they were exceedingly complimentary of UPMC and how they are delivering what they say that they will provide in each of their relationships.

All in all, the process continues to proceed very well.  I am very much encouraged by our continued interaction and their commitment to WMHS.  


Wednesday, March 8, 2017

DEA Presentation on Heroin and Opioids

All that I can say is WOW!  This afternoon at WMHS, we had a continuing medical education session with well over two hundred attendees, most of whom were clinicians.  The presentation was made by Charles “Buck” Hedrick, who works in Intelligence for the U. S. Drug Enforcement Administration and is based in Baltimore.  Buck provided a wealth of information and answered many great questions that followed from the audience.  
Virtually everyone who is involved with the Opioid / Heroin Crisis facing our community was in attendance.  There were law enforcement officers, psychiatrists, trauma surgeons, primary care physicians, hospitalists, nurse practitioners, dentists, ED staff, nurses, crisis counselors and Allegany Health Department staff in attendance.  
Some of the information that he shared included: 
  • the USA has 5% of the world’s population, but we use 80% of the opioids and 99% of oxycodone
  • there are 24 health departments and over 500 law enforcement agencies in Maryland so teamwork is key as has been the case in Allegany County
  • Baltimore is almost exclusively western Maryland’s source for heroin
  • the introduction of Fentanyl has set this epidemic apart from the others that began once soldiers started to return from Viet Nam
  • Fentanyl is used to enhance poorly produced heroin and it is a killer
  • there are over 100,000 clandestine labs in China producing drugs like bath salts and fentanyl
  • the DEA has three offices in China
  • one kilo of heroin can be bought for around $50K at the Mexican border but it can be cut 3 to 4 times with items like milk sugar and children’s laxative
  • you can buy one kilo of fentanyl online for about $3500
  • the world’s heroin comes from Southeast and Southwest Asia, South America and Mexico where the poppy crop grows the best
  • the DEA has a drug monitoring program where they buy heroin in Baltimore for the sole purpose of testing it to determine where in the world it is coming from
The most interesting piece of information was that 95% of the heroin coming into the US comes from Mexico via three routes: Interstate 5 to San Diego, Route 85 to El Paso and Interstate 35 to Laredo, Texas. (This should be reason enough to better control our southern border.)

Throughout his presentation, Buck repeatedly emphasized teamwork, the sharing of best practices, the need for medical school training of new physicians on prescribing, the success with using peer recovery specialists who can relate very well to those who are addicted, the benefit of mandatory prescription drug monitoring in Maryland, and law enforcement involving the DEA once leads are obtained.  

When an overdose occurs, it is first a medical emergency and then a crime scene. Sharing information and leads among law enforcement with the DEA can be most helpful in addressing the criminal side of this issue.  I, along with the rest of the audience, could have listened to Buck all day.  Like Jimmy Pyles and Sheriff Robertson, who lead many of local efforts on this subject, Buck was a wealth of information and brought a very global perspective to this crisis.