Defunding Obamacare, Really?

Last week, Sen. Ted Cruz spent 21 hours drawing national attention to Obamacare.  His goal was to get his colleagues in the Senate to defund the Affordable Care Act.  Really? You would think that he would realize what an impossible task he had at hand with the Democrats in control of the Senate and the White House.  But, if you really think about it, what were his real motivations?  

In my opinion, Sen. Cruz was getting a leg up on the run for the White House in 2016 over Rand Paul, Marco Rubio, Paul Ryan, et al by bringing himself into the national spotlight.  Over the weekend and into today, the game has turned to shutting down the government effective at midnight tonight into this game of chicken between the GOP on Capitol Hill, the Democrats and the President.  To what end?  With all of the waivers and exemptions issued to date, no one is really sure what the insurance side of Obamacare is going to really look like.  (Actually, the reform side has its merits.)  

Public opinion has turned, with the majority of Americans opposed to Obamacare, and the Administration has done an abysmal job of selling it to the American people.   If it is as bad as the GOP claims, let it be implemented and see what happens.  Anticipating a congressional staff exodus, everyone in Congress was exempted from the program.  How is the business community supposed to embrace the legislation if Congress applies a double standard and exempts their staff and everyone else on Capitol Hill?  

The bottom line is that in its current form the new law is unaffordable and the focus of the opposition should be bringing attention to the many perils of Obamacare.  The President should be doing a much better job of selling it and sticking with what he said from the onset of the bill's passage.  Too much flip-flopping has occurred on the part of the Administration bringing affordability and the many positive aspects of the bill into question.

New Waiver Positions Us for the Future

Today, Maryland hospitals announced our support for the state’s application to the Centers for Medicare & Medicaid Services (CMS) for a new Medicare waiver.  The key to the new waiver is that is creatively builds on the state’s current system to make Maryland’s hospitals ready for a new future of care, which has already started at WMHS.

The original waiver was based on the condition that Medicare’s inpatient costs in Maryland would not grow faster than they did across the nation. The new waiver expands hospitals’ focus from inpatient care to improving the coordination of care both inside and outside the hospitals.  The new conditions control costs, improve the patient’s experience of care and the quality of that care, and provide hospitals with more tools to improve the health of the communities we serve.  

There was a tremendous amount of work done over the past two years to craft this new waiver.  It was worth the effort since it will enable all Maryland hospitals reach the Triple Aim of higher quality, lower costs, and a healthier Maryland.

Looking for the Future of Health Care, Try Maryland

Yesterday, I read an issue brief that came across my desk from KPMG.  It was entitled, "Convergence through Accountable Care Capabilities."  There was an interesting quote from the brief that got my attention and it is as follows: "What is clear is that the transformation towards a more accountable health system cannot happen unless we are able to catalyze a series of simultaneous changes over the next three to five years.  New models need to be created, data needs to be shared, risks will need to be addressed and collaborative relationships will need to be formed."  

Now, how cool is it that at WMHS, as part of the ten-hospital Total Patient Revenue collaborative, we are already there?  TPR is certainly a new model based on value-based care delivery and no longer volume based, as a collaborative we share everything from data to best practices, we recognized the need to assume risk and can do so through improved quality and lastly, we have formed other collaborative relationships with just about every health care partner throughout our service area from pharmacies to urgent care centers to physicians to nursing homes and the list goes on.  Quite honestly, that is what got the attention of the NY Times to feature WMHS in their article on health care in Maryland.  So, the bottom line is that we don't need three to five more years.  We are now building on what we have mastered over the last three years in advancing the triple aim of health care reform: Better Care; Reduced Cost and Healthier Communities.

Another Health Care Comparison to the Airline Industry

Usually, hospitals are compared to the airline industry from a safety perspective and hospitals are routinely identified as woefully inadequate. The usual quote is that if the airline industry had the same safety standards as hospitals, gazillions of people would be dying in airline crashes each day. I exaggerate, but not by much. One can draw comparisons in some areas, but quite honestly, there are more differences than there are similarities.  

I have never really embraced this industry-to-industry comparison. However, this morning, I read an article by Jonathan Burroughs, entitled, "Six Strategies Hospitals Should Steal from the Airline Industry." It was a different approach, but an interesting one and one from which you could draw similarities. This article was tied to wasteful operations of which the airline industry has worked for decades to improve. The airline industry is far less complex than the health care industry, but there are a few, actually six, takeaways worth considering.

First, we need to master the flow of the entire health care system like air traffic control. We treat far too many aspects separately and not as a whole. I agree with that strategy. Second, airports function 24/7 and so should health care. In response many would say we do. Actually, we don't. We set up far too many aspects of our operations to benefit us rather than the patient. Third, all departures are scheduled in advance. We need to do a much better job in health care of performing effective discharge planning. At WMHS, we have seen a big improvement in d/c planning, but more emphasis is needed. Fourth, all arrivals are scheduled in advance. Some might say that many of our arrivals are unexpected, especially the emergent ones. That's not really the case. We know when the majority of our patients will arrive and when our downtime is with the fewest patients. We can and should plan accordingly. Fifth, flight schedules are smoothed throughout the day and week. Airlines schedule to ensure a consistent schedule. We can similarly manage non-emergent ED patients to a lower level of acuity and take appropriate steps to better receive patients in Surgery and ICU.  Lastly, delayed flights are taken off of main runways and taxiways. In hospitals, delayed discharges, transfers and admissions should be moved to comfortable locations and not tie up needed beds or resources.

By following these six strategies, we would be able to reduce cost, improve outcomes and be better positioned for health care reform. We should go to school, if you will, whenever we can bring improvement to the care delivery model in hospitals.........our future depends on it.

So, I am Not Alone After All

Yesterday, I was riding back from a meeting with two other executives and we got to talking about the number and tone of unsolicited emails inviting us to seminars, webinars, or meetings.  Those soliciting our business by offering to provide services and their "expertise" or taking us to the next level (whatever the heck that means).  Then today, I was reading Paul Levy's blog, "Not Running a Hospital" and it was on the same subject.......unsolicited emails.

I have blogged about this subject before, but it's nice to know that I have a lot of company.  In Paul's blog, he tells of a CEO who tried to unsubscribe from future emails only to be solicited further.  Then the CEO again asked to be removed and was insulted.   My favorite unsolicited email story happened a few weeks ago. I was solicited by a consultant to provide rapid improvement in the rapidly declining operations of my health system.  The consultant provided data that showed a steep decline in admissions, length of stay, use of ancillary services, etc.  I responded that I wouldn't be needing his services since we have redesigned our care to delivery model to focus on value and that we were no longer paid on a volume basis.  He responded that technically the data was correct and that he could still help right the ship, if you will.  In the politest of terms, I told him that he was an idiot and his services wouldn't be required now or ever.  

I still think the way to fight this problem is for all of us to have a change of heart when faced with an irritating consultant.  We should schedule face-to-face meetings with these "experts" and when they arrive simply be out of town when they show up at our doorsteps to woo us.  It's not very nice, but in time it will be very effective and if they don't get the message, they will be out of business.

It's a Gang Problem Not a Gun Problem

Over the weekend, I read a number of fascinating articles on gun violence in the U.S.  A great deal continues to be written about gun violence in the U.S. since the Sandy Hook Elementary School shooting in Newtown, CT, and culminating with last week's shooting of 12 innocent people at the Washington Navy Yard.  All senseless, unnecessary shootings, but with at least these two there is a common denominator with the shootings in the Aurora, Colorado, movie theater and the shooting of former Congresswoman Gabrielle Giffords and others in Arizona.  The shooters were all mentally ill.  But, yet the focus continues to be on guns.

Did you know that we have had the lowest number of gun-related deaths since 1981 in the US?  We have the highest concentration of gun ownership in the world, but yet the concentration of gun deaths occurs in our urban centers like Chicago, NYC, New Orleans, Washington DC, Philadelphia and Los Angeles.  These deaths are the work primarily of adult men between the ages of 18 and 39 with criminal records and a criminal past. Simply put, our high murder rate in urban centers is that of criminals killing criminals; these are gang members who are killing each other.  Those who kill innocent people like the above-mentioned incidents are mentally ill and those incidents are an aberration.   Those numbers, although horrific when they happen, are very low in comparison. 

Our high murder rates in the cities previously mentioned exceed the murder rates of most countries.  If New Orleans was a country, it would have the second highest rate in the world.  Over 80% of its murders are gang related.  If you look at the U.S. on a county-by-county basis, we are not a violent country.  The gun violence is in our major cities, not in rural America as the media and many of our politicians would like to have us believe.  As a country, the media should be drawing our attention to the need for more to be done for those who suffer from mental illness as well as the need to put the necessary resources into our urban centers to counter what has become a way of life to be a gang member.  There is a lot to be done, but playing the blame game isn't the answer.

Perfect Circle of Care

Several months ago, we piloted a new model for inpatient care called the Perfect Circle of Care.  This involves everyone from all disciplines who interacts with the patient working together as a team to improve the patient’s care and experience at WMHS.  Our patients on 7 North, where we did the pilot project, are telling us that the process changes we made with this new approach work.  This week, we expanded this concept to every inpatient unit.   All members of the Perfect Circle of Care team are demonstrating their commitment by signing a pledge to our patients that will be prominently displayed on their units.  Watch for the new posters the next time you visit WMHS.  Great job, everyone!

Smoking is Smoking

We are seeing an increase in the use of vapor cigarettes on the WMHS campus.  In some cases, patients and visitors are brazen enough to fire up their battery operated cigarette in physician waiting rooms.  Not so fast.  Smoking is smoking.  The second hand smoke from an e-cigarette may not be harmful, but the vapping process is harmful since the it's still nicotine.  Also, the FDA is finally getting involved and in recent studies found traces of toxic chemicals in the e-cigarettes.  Lots of additional study is needed, but in the meantime, we're not waiting.  At WMHS, we do not permit smoking of any kind, including e-cigarettes and we are changing our signage to reflect a prohibition of smoking of any kind on campus along with the use of any form of tobacco.  We obviously need to get as specific as possible so our patients and visiting public are well aware of where we stand.

More Quality Metrics

Two more quality metrics reflecting success at WMHS during our Fiscal Year ending June 2013 would be pressure ulcer prevention and hand hygiene.  With pressure ulcers, we reduced the number from 14 in FY12 to 3 in FY13.  That result is 2% and better than the national benchmark of 3.7%.  For hand hygiene, we ended the year with a 91.3% of employees and physicians observed by our many spotters washing their hands, which placed WMHS as a leader in the state.  Great results in both areas and so important in the care of our patients.  Hand washing is required to reduce infections in the hospital.  For every hospital-acquired infection, it not only jeopardizes the health and well being of our patients, but it also costs WMHS over $100,000 for each infection acquired in the hospital.  The attention to detail and the commitment made by our staff and physicians have been exceptional over the last year and our results prove it.  Great job.

On the Cusp

The Maryland Hospital Association has had a quality initiative underway for the last few years in which WMHS has participated.  Three performance areas associated with reducing infections were absolutely key and they included CLABSI (Central Line Associated Blood Stream Infections), CAUTI (Catheter Associated Urinary Tract Infections) and VAP (Ventilator Associated Pneumonia).  At WMHS, we have seen a dramatic improvement in all three areas. 

With CLABSI, we increased by one incident between last year and this year; however, we were better than the state average with only seven incidents.  For CAUTI, we went from 28 in FY '11 to 26 in FY '12 and then saw a dramatic reduction in FY '13 to 5 incidents.  We were recognized by the State for our program success.  For VAP, which focuses on two patient units, ICU and Cardiovascular Unit, we ended FY '13 with zero incidents from 6 and 7 incidents the two previous years.  In each instance, we have dramatically improved our care delivery models and the outcomes have been remarkable.  A lot of people contributed to our success.  We had to stress the criticality of working as a team by breaking down those long established silos and it worked.

The Washington Navy Yard

So this morning I get out of a meeting and there is a phone message from my wife that reads, "Jeff did not go to the Washington Navy Yard this morning."  My reaction when I looked at it was, "Huh, why did I need to know that?"  Then I learned of yet another senseless shooting.  Last count was 12 dead.  Innocent people going about their business and shot dead.  It makes me sick.  The significance of Jeff is that he is my daughter's boyfriend, also a Navy Lieutenant, who is in town to see my daughter and to visit his next assignment, you guessed it at the Washington Navy Yard.  He was scheduled to be there this AM to get introduced to his new work area and the people with whom he will be working.  He will begin work there in November.  I am pleased that he is safe, but my heart aches for the loss of life and for those who were injured.

17th Annual WMHS Golf Tournament

Today, we held our 17th Annual WMHS Golf Classic.  What a beautiful day for golf.  More importantly, we will have netted over $100,000 from the overall golf, corporate sponsorship, silent auction and the live auction.  Last night's dinner raised $3,200 from the silent auction and the live auction raised $29,000.  Thanks to a lot of people who work very hard year after year to make this event be successful.

All's Not So Rosy in Maryland

Two stories caught my attention this week regarding living in Maryland.  First, Governor Rick Perry from Texas is running ads this weekend in the suburban DC area inviting Marylanders to relocate to Texas.  His message is directed at businesses and individuals who are fed up with the billions in new taxes that have been added over the last six years.  In his ad, he says that Texas has added more jobs throughout this recession than all of the other 49 states combined.  That's pretty remarkable, if it's true.

The other story is the intention of the guy from Carroll County who wants the five most western counties in Maryland to secede from the state.  He is tired of the high taxes; not having representational government as a Republican since the Governor and the majorities in the House and Senate are all Democrats; the focus of state leadership being concentrated on Baltimore City, Prince Georges County and Montgomery County; and lastly, the anti-business mentality.  Most are valid points and I hope that such initiatives get the attention of the politicians in Maryland that the state is more than three regions.  I recognize that's where the majority of the votes are but they have a responsibility to the residents / voters of the entire state. I am not moving to Texas nor do I support forming West Maryland, so my hope is that the citizen leadership in western Maryland continues to work with elected officials across the state to foster a greater fondness for this part of the state.

Lest We Forget

What an appropriate title to today's blog.  I was prepared to blog about an entirely different topic and when I typed the date, it hit me.  So, I did forget based on how hectic the last few days have been.  However, I have to blog about September 11, 2001.   I can't remember feeling the shock that I felt when I learned what had happened in NYC, Northern Virginia and Shanksville, PA, ever before.  That awful awareness when that second plane flew into the other tower of the World Trade Center and at that moment realizing it was an attack on our nation and not just a horrific accident.  But, then came the unity of a nation and the outpouring of patriotism from coast to coast.  A country rallying around President Bush and Mayor Giuliani, no matter whether you liked or disliked either man;  it didn't matter whether you were a Democrat or a Republican; there was an outpouring of support for what needed to happen from a grateful nation as well as throughout the world.  This date has to remain a very special and solemn day for decades to come.  It can't become diluted with everything else that is happening around us.  It's been 12 years, but it still seems like yesterday.

Local Recognition of National Attention

Recently, I commented on a lack of coverage about the NY Times article by the local media in Cumberland.  That all changed this past Sunday when the Cumberland Times News did a feature story (above the fold front page) on the NY Times article.  Article is attached.  The CTN actually sent a reporter who interviewed our Chief Financial Officer and our Chief Medical Officer for the story.  Both were able to expand on our successes even beyond the NY Times article.  The reporter also included aspects of the original NY Times article.  All was very positive and I appreciate the recognition by the Times News.

http://times-news.com/latest_news/x789524231/WMHS-gets-national-attention-for-success-with-revenue-model

Five Hard Things

I read a piece this a.m. from the Governance Institute on Moving Forward Together.  Ken Kaufman of Kaufman Hall, a renowned health care consultant, laid out five disruptive steps, as he calls them, that organizations must take to prosper in the difficult health care environment ahead.  I like to compare our progress against such suggestions as I read them.  His five steps are:

·         Downsize the Delivery System - Stop offering services where the volume of patients is inadequate or where there are financial losses.  Easier said than done with the volume issue.  In our community, we have to offer services in a number of areas even if we are losing money because we are the only game in town.  We are constantly assessing and reassessing those services that we deliver; and if something changes in the industry that will allow that service to be changed, we will do so.

·         Reduce Unwarranted Variations in Care - Use data to evaluate physician performance and where individual physicians rank poorly, work with them on changing how they practice.  We have seen a great deal of success in this area, but there are a handful of docs with whom we are working more closely.  They have been informed that if you don't change then you won't be practicing at WMHS.

·         Eliminate Unnecessary Tests and Procedures - We are no longer paid on the volume of tests performed.  As a result, we have been reducing our ancillary use rates considerably.  We have a ways to go, but we have made great headway.

·         Address the Crushing Cost of Medicare - We need to better manage the care of all of our patients, especially the frail and elderly.  Five percent of the Medicare patients account for thirty percent of the cost.  At WMHS, we have a number of initiatives in place to better care for these patients as well as those who have multiple illnesses and who frequently return to the hospital.

·         Improve End of Life Care - In the late stages of life, many patients receive unnecessary care that drives up the cost of care.  At WMHS, we have done a great deal in expanding our palliative care programs.  Dr. George Garrow, our Chief Medical Officer, has brought his expertise as an Oncologist to this program, which has both been improved upon and expanded.

As Ken Kaufman puts it, the health care industry has been given permission to change.  At WMHS, we took advantage of that permission given to us by the Health Services Cost Review Commission and we have done so very well.  As I have described in the past, but not without many challenges.  We have improved the quality of care, the overall patient experience, the cost of care and the health of our community.  We have become THE health care company of our community.  We have taken on risk and provide services along the continuum of care through WMHS or through the many partnerships that we have developed over the last three years.  At WMHS, we are moving forward.

Food Insecurity

There was an article in the paper yesterday on food insecurity, which is a term that I was unfamiliar with.  It is defined as the disruption of eating patterns or a lack of food consumption due to a lack of money and access to food. 

Food insecurity is affecting 49 million Americans who are mostly poor, female headed households, families with children, Blacks and Latinos.  One in five households with children is affected by food insecurity.  The US is continuing to set records in this area for the fifth consecutive year.  This certainly is not a set of statistics that we can be proud of;  in fact, it's disgraceful.  As country with the kind of wealth that we have, as well as the extent of government support through a plethora of entitlement programs, no one should be wondering where their next meal is coming from.

 

Locally, I have pledged to Kim Repac, CFO at WMHS and a newly appointed board member for the Western Maryland Food Bank, that the health system needs to step up and do more to support the Food Bank.  All they need to do is to tell us how we can help.

Redesigning Care Delivery

This morning, I read a quote on the redesign of care delivery offered by James Skogsbergh, CEO of Advocate Health Care, the largest health care system in Illinois. He said "It takes more time to build new infrastructures than any of us think.  Whatever amount of time you thought it would take, double it."

He's right.  At WMHS, it took us well over two years to redesign our care delivery model from one of volume based to value based.  We thought that it would take a good year to year and a half.  We finally saw progress during the last half of FY'13, which ended June 30, 2013, two and one half years later.  There was a great deal of education involved with stakeholders, the Board, the medical staff, our employees, our patients and the community.  We had a number of starts and stops with the many initiatives that we had to put in place.  We were constantly re-evaluating the many aspects of care delivery, from patients going home with their medications to developing care plans for patients post discharge.  We added new staff to Care Coordination, Pharmacy, and RN Transitionists for the nursing home patients, Care Link Coordinators and the list goes on.  We reinvented the delivery of care and it took longer than anticipated, but we are all better because of it.  We reduced the cost of care; our patients are better cared for in a multitude of settings from acute care to clinics to home; the health of our population hasn't worsened and we have seen some improvement in a variety of health status areas such as obesity, tobacco use, access to care to name a few; and we have once again become profitable so we can reinvest in continuing to seek new ways to better care for our patients under this redesign of care delivery. 

The staff at WMHS have a lot to be proud of with what has been accomplished over the last several years.

Upgrading Your Life

I was thumbing through the summary of a new book the other day, "Upgrade / Taking Your Work and Life from Ordinary to Extraordinary" by Rana Florida. 

The author asked some famous people as to how they made things work so well for themselves.  From her work, she came up with six principles to leading fulfilled, successful lives:

1. Envision your future
2. Realize your passion and creativity are key to everything
3. Protect your time
4. Collaborate
5. Take risks
6. Embrace failure as a part of success

Actually, I can relate to the principles and could add a few, such as never forget where you came from, there will always be luck involved and prayer can pretty worthwhile in lots of situations.  

According to the summary, Rana Florida, who is a columnist for the Huffington Post, presents her insights and findings in an engaging way.  She says that the majority of us are riding through life in coach class and that the book should motivate us to get an "upgrade."  I have added her book to my reading list of at least two management / leadership type books per month.

A Chaplain Who Doesn't Believe In God

The other day I read an article about a guy who wants to be a Navy Chaplain but he doesn't believe in God.  Really?  He has a Master's in Divinity from Texas Christian University and another Master's in Ecclesiastical History from Oxford, but he is a Humanist. 

A Humanist is one who advocates for equality among Freethinkers, Atheists and Humanists.  Being a Humanist means a lot of different things according to their website.  In a nutshell, they don't seem to be big fans of God but seem like very good people based on their beliefs.  Clearly, not believing in God is the wanna be Chaplain's right, but to be a Navy Chaplain which is synonymous with being a man or woman of God?  What on earth is he going to talk to the 13,000 declared non-believers in the Navy about?  Good clean living?  Actually, that's what your superior in the Navy is charged with and many are very good at it.  In addition, a "real" Navy Chaplain could also be there to listen and guide a non-believer when they are in need without imposing his or her faith on the sailor.  Oh wait, he says that because of his religious training and background, he can still minister to the believers. But he still doesn't believe in God; how do you suppose that will work?  He says that his life is one of ethical personal fulfillment aspiring to a greater good of humanity.  What he stands for sounds very good, but to serve our country as a Navy Chaplain who doesn't believe in God just seems to miss the mark.  What is crazy is that our current Defense Department is considering his application.  They say that they don't endorse any specific religion or organization (since when?).  They observe the tenets of a member of the military's respective religion as well as those who have no religious beliefs.  Sounds like political correctness to me.  What's next for our military, pilots who don't fly; a Surface Warfare Officer who doesn't like the water; a claustrophobic submariner who never wants to go below the water's surface.  I have no problem with this guy wanting to serve in the Navy but do so in a position that makes sense. 

In closing, I'll leave you with a quote from Congressman John Fleming, who says, "The notion of an atheist chaplain is non-sensical; it's an oxymoron."  Well stated, Congressman.