The Challenge of Preventing Readmissions

The readmission rate at WMHS has dropped over 20% from about five years ago to around 10% today.  Reducing readmissions is critical since we are not paid for those re-admissions within 30 days if the readmission is related to the same co-morbidities or disease classifications.  A recent article in the Wall Street Journal calls into question as to just how much control hospitals have in controlling readmissions.  The article states that it is a worthy goal, but can jeopardize the health of the patient and the bottom line of the hospital.  I am not concerned about the bottom line since WMHS is paid on a value basis, but we are always on guard to ensure that if the patient requires readmission that they are re-admitted.  We don't withhold care because of a penalty; we try to learn from the reasons as to why the patient had to be re-admitted.  There are many reasons for readmissions and some can't be prevented, but hospitals can play a role in preventing them.  One factor was discharging patients too soon.  We perform a chart review on every readmitted patient as well as interview the patient and / or family members to ascertain why the readmission occurred.  We have found that there is less that we can do for the non-compliant patient as well as the poor and the elderly with little to no family support.  The social factors contribute greatly to readmissions and as a safety net provider, in this case, we carry a greater burden due to the lower socioeconomic status of our population.  Our philosophy has been that we need to control the readmissions that we can and work with the non-compliant, the poor and the elderly in other ways to hopefully prevent readmissions in the future.

Additional Tidbits from Anirban Basu

Yesterday, I blogged about our board meeting last Friday and the value that Anirban Basu brought to our board.  In yesterday's blog, I focused on his presentation related to the proposed alliance; in today's blog, I will provide some of the additional information that he covered.  His tidbits worth sharing are as follows:

The US economic recovery is in it's fifth year but still very weak at 2.1%

Health Care spending is at it's lowest in 50 years; the average annual growth has slowed to 3.5% over the past five years and 1.5% is attributable to inflation

The contributing factors to the slowing of health care spending are use rates are down, quality reimbursement has been instituted along with evidence based medicine protocols.  The recession also played a part

The increase in the national debt for 2012 was $1.7 trillion and for 2013 it's "only" $640 billion

Since April 2013, we have added just under 200K jobs; in a year the US has added 2.3 million jobs predominantly in the business sector but many are temporary or part time jobs.  Other leading sectors include: Hospitality, Travel, Transportation and Health Care.

By 2020, the US will be the largest producer of oil.  Currently, we are third with Saudi Arabia being first and Russia second.

The states with the greatest job growth are all oil producing states: Idaho, Texas, North Dakota, Utah, Montana and Nevada.  The economies of Arizona and Florida are racing back to normal with new housing and tourism.  Maryland is 14th  due to the high number of government jobs added, but of late our unemployment rate has increased to 7% (national rate is 7.6%)

The US is unique in that health care delivery is very comprehensive.  Cardiac surgery being delivered in western Maryland would not occur for example, in England.  Hospitals that are located outside of large cities in other industrialized countries provide primary care for the most part.  Individuals have to travel to large cities for comprehensive health care services.

Health care expenditures at 18% of the Gross Domestic Production is still high for an industrialized country but not as high as some may think for a civilized compassionate society like the US

As I blogged yesterday, Anirban is fascinating with his wealth, scope and depth of knowledge.

A Brave New World

Last Friday, the WMHS board met for their annual strategic planning meeting.  We were honored to have Anirban Basu as our guest presenter. Anirban is the CEO of the Sage Policy Group in Baltimore; he is an attorney as well as an economist.  He specializes in economics of economic development, health care and government.  The primary purpose of inviting him to present at the meeting was to gain valuable insight on where health care is going and to assist the board in deciding as to whether or not the proposed alliance with Meritus Health and Frederick Health System is in the best interest of WMHS and the region that we serve. 

According to Anirban, the Accountable Care Act has created a land of giants resulting in a diminishing role for smaller to medium sized hospitals and health systems.  He said that bigger is better in delivering care at a lower cost and with greater efficiency.  He said that the Accountable Care Organization of which we would pursue with this proposed alliance requires a larger network formation.  There is far too much risk to be taken and smaller organizations can't handle that amount of risk nor the cost of forming an ACO. 

In 2010, there were 72 hospital consolidations; that number grew to 92 in 2011 and 94 in 2012.  The number is expected to grow to well over 100 in 2013 and the trend is expected to continue.  In Maryland, WMHS is one of 15 independent health systems left out of 46.  That number continues to shrink with University of Maryland Medical System, Johns Hopkins and MedStar in discussions with some of the 15 independents as well as those hospitals in DC.  Anirban discussed the cost pressures on hospitals that are coming from every direction.  These pressures include technology, physician recruitment, retention and employment, depreciation, rate regulatory challenges, Medicare, Medicaid, declining revenues and growing competition just to name a few. 

In this Brave New World, there are a lot of changes occurring now as well as on the horizon.  We have to be ready to not only continue to exist in this community but to thrive; it is clearly in the best interest of our patients, this health system and the community.

I Want to Thank Those Charity Care People

Last week, a member of System Management was approached by an acquaintance, who with tears in her eyes, said that she wanted to thank those people who provide the Charity Care Fund at WMHS.   She said that her daughter was seriously ill and in the hospital.  She has no health insurance and no money to pay for her care.  The family was told that it was OK; Charity Care will take care of it.  So, in turn, the mother wanted to send a letter to the people who fund Charity Care.  The WMHS employee said that the health system funds Charity Care for those patients who can't pay.

Some of that care is covered in the hospital rates that have been established through Maryland’s unique reimbursement system, but that continues to fall short year after year.  There are a host of steps that we walk people through to obtain financial assistance.  But when it's all said and done, the health system takes a loss for the care that was provided to those who couldn't afford to pay.  And that amount has grown dramatically over the last several years.  Last year, the total amount for our Community Benefit was just under $40 million, with almost $16 million being provided in the form of charity or uncompensated care. 

We are fortunate to have some funds that will cover minimal needs for our indigent patients, but nowhere near the magnitude to cover the cost of the care for a serious illness.  The woman was shocked that WMHS covers those costs and said "I am sure that most people have no idea that the health system covers those costs."  I guess this is another opportunity for WMHS to do some "shameless" self-promotion.

CMS to Link Physician Pay to Quality

Finally, CMS is beginning to align incentives between providers.  Right now, WMHS is paid on a value-based care delivery system, while many of our physicians continue to be paid based on volume.  As of 2015, physician pay for those physicians working in large groups (100 or more) will have a portion of their pay at risk.  They will get bonuses or be penalized.  It looks like our physicians who are in mostly small practices (less than 9) will have to wait until 2017. 

The program will be similar to the Quality Based Reimbursement program in Maryland based on a zero- sum game.  There will be winners and losers since there is no new money for the bonuses.  Through our President's Clinical Quality Council, we have been working with our physicians to get them to understand how the QBR program works and impacts us.  The intention has been to better prepare them for what's on the horizon with CMS's Pay For Performance (P4P) plan.  Under the CMS P4P plan, quality measures for physicians will be based on basic medical approaches, and initially physicians will get to pick the measures by which they want to be judged.   I realize that many physicians are not excited about the new pay plan, but it is a start in getting all providers aligned with each other.  Stay tuned.

President's Clinical Quality Council Enters Its Third Year

The President's Clinical Quality Council was formed in 2011 and has been meeting monthly since its inception.  To take you back, the Council was formed to create a vehicle for closer alignment with our physicians.

The members of the C-Suite recommended medical staff members who were leaders of the medical staff (either official or unofficial) and were considered early adopters or change agents.  I selected the first six from that list and then we asked the six newly appointed members to provide six names of physicians whom they would like to see join them on the Council and who met the criteria for selection.  Through that process, we created the Council of 12 and it has been very successful.  Over the last two years, we have used them primarily as a sounding board on initiatives such as improving communications, getting a better handle on our high utilizers, improving physician documentation, reducing our preventable conditions, eliminating denials, reducing readmissions and, of late, developing a pay for performance (P4P)  initiative. 

As we enter our third year, in addition to focusing on P4P, we will be asking this group to work with us on clinical integration within WMHS as well as with the proposed alliance between WMHS, Frederick Health System and Meritus Health in Hagerstown.  Should the boards of the three health systems decide that this alliance is in the best interest of their respective communities, clinical integration will be a critical component of the alliance going forward.  The expertise and input from the Council will be essential.

An Education That Could Have Just Saved My Life

As I blogged yesterday, last week I had the opportunity to spend some time at the Center for Diabetes Management.  Much of my time was spent with Jennifer, one of the Health System's Dietitians and a Nutritionist for Healthier Eating. 

Talk about time very well spent, WOW!  I learned that my daily intake of Carbohydrates could actually kill me.  As an example, I go to the gym on Saturday mornings and workout for about an hour and a half.  I then come home for what I thought was a hardy, but healthy breakfast.  I would have a smoothie with a half of banana, a handful of raspberries, blackberries, blue berries, strawberries, OJ and yogurt.  I would then have a bowl of cereal with the other half of the banana.  I would round out my "healthy" breakfast with a whole grain muffin with peanut butter.  Total servings of carbs for that one meal was about 13.  The maximum about for me should have been 4.  That's right, four servings of 15 grams of carbohydrates per meal, and I was eating three times that amount.  Sure there are healthy items that I was eating, but far too many carbs.  Carbs turn to glucose, which is an energy source for your body and is something that your body needs.  My body needs to have the same amount of carbohydrates at about the same time every day. 

So being in a pre-Diabetic state as I blogged about yesterday, my pancreas may not be functioning properly forcing my blood glucose levels to get too high.  As a result, I need to control my blood glucose levels through my food intake and balance my carbs accordingly.  The hope is that I caught all of this in time.  Since last Thursday's educational session, I have changed how I eat, dramatically reducing my carb intake.   Another example of a high number of carbs that I found amazing is a baked potato.  A large baked potato with nothing on it is four servings of carbs for one meal, which would be the max for me.  Add to that all of the dressings for that baked potato, a vegetable, a roll or two, a cocktail before and / or during dinner and the carbs keep adding up.  

I told Jennifer that I was blown away with the information that she shared with me.  I thought that I had a good understanding of healthy eating, but actually, I didn't have a clue.  I would strongly suggest that everyone gain a much better understanding of carbohydrates and what they can do for you as well as what they can do to you.