Now What !?

At 7:30am on Wednesday, November 9th I received a Helen of Troy type text message: three simple words from a client that begged a thousand responses, simply asking, “now what?”

Unless you’ve been hiding under a rock for the past few Trump Winsweeks you are aware that healthcare in the United States is once again heading into turbulent policy waters with the election of a president whose political party has very different ideas about how to improve our healthcare delivery system. Or so we have been led to believe.

From what little is known to this point it is unlikely the Trump Administration will just blow up the Affordable Care Act in the first 100 days of its tenure. That is fortunate because, irrespective of your political beliefs, haphazardly dismantling the current system would undoubtedly result in unintended – and politically undesirable – consequences, potentially causing harm to millions of patients and healthcare providers.

That being said, there is no doubt substantial changes will be made and quickly by Washington, DC standards. If anything is predictable about Mr. Trump it is that he won’t be patient with bureaucratic efforts not quickly producing tangible results. Whether that impatience can be channeled into effective change management in a kingdom that literally thrives on maintaining the status quo only time will tell.

The next six months are going to be incredibly confusing and confrontational as we seek to consider and understand the potential ramifications of new health policy proposals. Speculation on the impact of such proposals will span from certain and imminent catastrophe to unbridled joy. Through it all be reminded that often in many ways the more things change the more they stay the same. To that point, in helping senior living organizations anticipate how to best position for changes in healthcare policy I think it is more prudent than ever to focus on what we know won’t change.

The accelerating demand for affordable housing, home and community-based services and healthcare resulting from the demographic realities of an aging population will not change. Underlying pressures such as technology and innovation driving up healthcare costs will not change. The growing impact of consumerism on healthcare will not change. Demand for qualified human caregiving resources outstripping supply will not change. The increasing burden chronic disease management puts on our delivery system will not change. I’m sure you can think of your own realities to add.

If you aggregate all of the environmental certainties shaping the healthcare industry today and in the future, logic dictates that value will continue to be at the center of new policy initiatives. And that means alternative payment models (APMs) will continue to garner support if not greater efforts to accelerate their adoption. Recall, the Medicare Access and CHIP Reauthorization Act (MACRA) provides substantial incentive for physicians to migrate into advanced APMs, and that legislation was passed by Congress with overwhelming bipartisanship. MedPAC, the nonpartisan legislative branch agency that provides Congress with analysis and policy advice on the Medicare program has also been very supportive of APMs.

So when answering the question, “now what?” my response is to continue developing organizational attributes that will build competitive advantage as a participant in APMs. Focus on the no regret investments that build enterprise value in the context of emerging care delivery models: e.g., demonstrating a commitment to continuous quality improvement; assess the value of specialization; improve productivity and reduce costs without impacting outcomes; develop an employee value proposition; build a robust cost accounting system; focus on beneficial referral relationships; measure and report on performance; invest in community-based downstream relationships.

A great way to learn more about what APMs entail – and to stay ahead of emerging research, ideas and discussion about their advancement – is to join the Healthcare Payment Learning & Action Network (HCPLan). This is a nonprofit organization that was launched by the Department of Health & Human Services in March of last year with a mission, “to accelerate the health care system’s transition to alternative payment models by combining the innovation, power, and reach of the private and public sectors.”

On October 25th of this year I had the opportunity of attending the fall LAN Fall Summit in Washington. The Summit brought together nearly 800 participants representing senior leaders from across the health care community, including providers, payers, employers, patients, consumer groups, health experts, and state and federal government agencies.

Here’s the singular most important message that I would like to share from my participation there: alternative payment models are not unicorns. They exist, they are being tested, learned from and gaining increased support daily. They are transcending the ideological spectrum of political discourse. The advance toward APMs is accelerating, and as shared above I do not see that being at all abated by the results of this presidential election. I can see the opposite effect taking shape.

Sadly, I believe there will come a time in the not too distant future when many nonprofit and smaller senior living organizations that depend upon post-acute/long-term care revenue for survival will find their organizations have waited until the decision of whether or not to participate in APMs has been taken out of their hands. For profit organizations are investing millions in learning how to compete and win under alternative payment models. If your organization is not taking steps to be equally competitive, then I would focus your energies instead on building acquisition value.

The first step in determining whether and how your organization can be competitive in a world of value-based care delivery models is to perform a gap assessment: what attributes must you have to compete under APMs compared to your organizational current state – and what investments are required to bridge that gap? Do you have the financial wherewithal to make those investments? How much time do you have to effectuate change?

That’s now what.

  ~ Sparky

National Study of Long-Term Care Providers

National Study of Long-Term Care ProvidersFor those policy wonks out there looking for resources to support your work here is a phenomenal publication that you need to be familiar with. The National Study of Long-Term Care Providers is sponsored by the Center for Disease Control and Prevention’s National Center for Health Statistics. Data, information and analysis is presented in an integration fashion that is designed to monitor trends in paid, regulated long-term care.

Five sectors are included:

Adult day service centers and participants
Home health agencies and patients
Hospices and patients
Nursing homes and residents
Residential care communities and residents

The main goals of the study are to:

Estimate the supply and use of paid, regulated long-term care services
Estimate key policy-relevant characteristics of providers and users, and practices of providers
Produce national and state-level estimates, where possible
Make comparisons within and between sectors
Examine trends over time

And not just policy wonks will benefit from the depth of knowledge and information provided by this initiative. Those in the senior housing and post-acute/long-term care business will benefit by having insights and understanding of utilization patterns, disease incidence, clinical and operational characteristics – across provider types. As the industry transcends away from its silo-based legacy toward the integration of community support, services and care across organizations having an understanding of how these provider types can work together to provide greater value will be a fundamental requirement to economic survival.

  ~ Sparky

Only Innovation Will Reduce Readmissions

Body, Mind, Soul, And Spirit ConceptAs reported on yesterday in Kaiser Health News, over 2,600 US hospitals – the most to date – will have their average Medicare reimbursement rates reduced over the period October 1, 2014 through September 30, 2015, due to the Hospital Readmissions Reduction Program. The overall reduction is projected to realize $428 million in savings to Medicare – i.e., translated as lost revenue to hospitals.

For anyone still unfamiliar with the reductions program, in a nutshell it is an attempt to use public policy to achieve more efficient alignment between patent care requirements and the overall cost of care provided – particularly to the extent costs are driven by care setting. Or, more pragmatically, Medicare does not want to pay the comparatively higher overhead costs associated with acute care settings if a patient’s readmission to that setting could have been avoided.

Of course, there’s the rub that will eventually have to be reconciled if the program is to remain: can we really objectively and often times arbitrarily determine what’s avoidable? The primary reason this is so difficult is because of the myriad environmental considerations that impact patient recovery and sustainable treatment away from the acute care setting. Where someone lives (housing), their neighborhood, their human support network, access to transportation, cognitive state and capacity for engagement, recognition of comorbid considerations such as anxiety and depression – the list goes on.

Hospitals and their clinical teams are taking the readmission program seriously. A three-percent reduction in revenue from your largest source when you are already struggling with narrow margins has that effect. New efforts to forge relationships with post-acute/long-term care providers, patient communication strategies, multi-provider think tanks, post-discharge follow-up programs, transitional care planning, utilization of telehealth and telemonitoring technology, targeted disease intervention – these primarily represent the extension, or repurposing, of core clinical capabilities.

Not to discount the importance of these initiatives, but by and large there is nothing all that innovative here when compared to the fundamental nature of the problem we are trying to solve. And there is a limited ability to address the fundamental challenge driving hospital readmissions: the environmental obstacles shared above. Worse yet, these tactical approaches fail to embrace the holistic reality that is patient treatment and recovery.

That’s where innovation efforts have to be focused: not on keeping someone out of the hospital but on removing the environmental obstacles that drive readmissions as a consequence of undesirable recovery and sustainability. As Toby Cosgrove, President and CEO of the Cleveland Clinic wrote earlier this week, “as my friend Professor Michael Porter of Harvard Business School says, innovation is the only solution to … long term issues faced by American healthcare.”

And it will ultimately be the only solution to lowering hospital readmissions.

  ~ Sparky

What’s Your Performance Improvement Strategy?

If you are a post-acute/long-term care provider still sitting on the sidelines waiting for a clearer understanding of how Healthcare Reform is going to impact your organization’s future, well then all I can say is, “Good luck with that – let me know how it works out for you.”

In an article published this past weekend (Medicare Seeks to Curb Spending On Post-Hospital Care), Kaiser Health News’s Jordan Rau reported on the wide variability in Medicare spending on post-hospital care across the county – and the attention that it is getting from CMS. Attention that is quickly turning to targeting: as in even more deeper cuts in reimbursement.
Several of the examples included:

Medicare recipients in Connecticut are more than two-times more likely to be admitted to a nursing home than residents in Arizona.

Medicare spends an average of $8,800 on a patient’s home healthcare in Louisiana – while spending $3,800 in New Jersey.

The rate at which beneficiaries receive post-acute services covered by Medicare in Chicago is three times the rate in Phoenix.

And the aggregate economic impact of variability in per capita spending is substantial. As the growth in post-65 age cohorts continues to accelerate both the inherent cost contribution (demand) as well as cost-push inflation (a result of seeking to satisfy that demand with scarce resources) is increasing. As reported in the Kaiser article, Medicare spending on PA/LTC, “has grown at 5 percent a year or faster in 34 of the nation’s 50 most populous hospital markets in recent years.”

The article goes on to describe the perceived reasons behind the variability that has captured CMS’s attention:

Misaligned incentives: Hospitals have not historically been economically impacted by the consequences of post-hospital care delivery, while PA/LTC providers have been incentivized to drive utilization based upon maximizing reimbursement rather than the appropriateness of the setting.

Information asymmetry: Very often PA/LTC referrals are a function of personal relationships and familiarity between those responsible for discharge planning and those responsible for marketing available beds.

Provider ambiguity: The evolution and confusion that today characterizes post-acute care services and settings (and the impact technology is having on care settings – e.g., telemedicine) often impairs market competition.

Lack of care coordination: While post-discharge readmissions have captured the popular media’s attention because of the ACA payment penalty, it’s the underlying lack of care coordination between acute and PA/LTC providers that results in cost inefficiencies extending well beyond avoidable readmissions.

These concerns, taken together with other indicators of potential waste and inefficiency (please refer to the article cited), will drive tremendous pressure in the years ahead to lower Medicare post-hospitalization expenditures (thus the chainsaw metaphor). How PA/LTC providers address these pressures will mean the difference between staying in business – or not.

When thinking about performance improvement as a vehicle to address this challenge remember this: more than any other singular criteria, successful PA/LTC organizations that survive the next decade will have learned to trade on value. Value in healthcare is quite simply the patient’s satisfaction with the care delivery experience divided by the cost to provide that experience (with the notable understanding that a patient’s satisfaction is typically augmented by their families’ satisfaction). With or without the Affordable Care Act, that is where the industry is headed.

But what does it mean to, “trade on value?” To help Pub visitors begin thinking about that I have provided a few fundamental questions that you might want to ponder – or discuss with colleagues:

  1. What’s most in demand?
    If Medicare, Medicaid and private insurers were to evaporate tomorrow, what core service offerings that you provide would be the most likely to still generate revenue? What distinguishes those services from others?
  2. Where do we fit in the care continuum?
    Forget the fancy charts and graphics of think tanks and consultants showing you where you fit. Think about the patients you care for every day from the perspective of their overall care experience: where does your organization provide the greatest value to that patient’s recovery along the care continuum?
  3. Who wants to work with us?
    How do potential partners in your market determine their value? Based on that understanding, can you enhance their value? What are the risks that you would lower it? Can you effectively address those risks?

  4. How do we protect and enhance our core value?
    In healthcare, more than any other industry, the innate ability to produce value is primarily attributable to direct caregivers. What should you be doing today to ensure you protect that most valuable resource? And what should you be doing tomorrow to help those caregivers increase the value you provide to patients?


QAPI ~ Ready (or Not?)

2013-01-09_14251sI have been receiving a fair amount of anecdotal intelligence that many post-acute/long-term care providers are not at all prepared to implement the Affordable Care Act’s QAPI when (still waiting . . . ) those regulations ultimately get published. So I thought sharing this post again might be useful.

Section 6102(c) of the Affordable Care Act – Quality Assurance and Performance Improvement Program (or QAPI) requires the Secretary of Health and Human Services (as delegated to CMS) to, “establish and implement a quality assurance and performance improvement program …” and to, “…establish standards relating to quality assurance and performance improvement with respect to [nursing] facilities and provide technical assistance to facilities on the development of best practices in order to meet such standards.“

Last Friday CMS released a memorandum to state survey agency directors announcing the rollout of electronic assistance and compliance-oriented materials on the QAPI website. HHS/CMS has still not yet published the condition of participation regulation that will provide nursing facilities with compliance guidance (facilities were to have already been compliant in March of this year), but there already exists comparable regulations for other healthcare provider types that will serve as a template. Once that regulation is finally published nursing care providers will have one year to develop an acceptable QAPI plan.

QAPI compliance for nursing facilities is not entirely new. The nursing facility QAPI is based in part on existing Quality Assessment and Assurance (QA&A) regulations. However, the new planning and reporting provision significantly expands the level and scope of QAPI activities that nursing facilities must enact in order to ensure they continually identify and correct quality deficiencies as well as sustain performance improvement.

It is a tad ironic that in promoting a key differentiator between historic, traditional quality assurance – now being coupled with performance improvement – that while quality assurance is to be viewed as a requirement and reactive, performance improvement should be viewed as discretionary and proactive. Never mind that performance improvement is being mandated as part of the QAPI program. Sort of like being able to choose any whole number between zero and two, right?

Anyway, I really fear that for a lot of nursing facilities – particularly smaller and/or single site organizations – this requirement is going to sneak up on them. And the true impact of that reality will not just be the regulatory and economic consequences but the lost opportunity to utilize the QAPI process to drive better quality, higher safety and better outcomes – while lowering the overall cost of care.

There are two ways to view the new QAPI requirement: another onerous regulation designed to burden caregivers with unnecessary compliance requirements at additional cost; or an opportunity to sponsor and embrace a process that – if done strategically and conscientiously – should improve productivity and efficiency while strengthening market position based on quality and outcome characteristics.

So my counsel is don’t wait for the regulation to be promulgated. Start now to learn and understand the tools that have already been made available. CMS has stated that, once provided, the QAPI formal regulation will not contradict the materials that have already been developed and provided.

And for those organizations that are truly interested in taking a strategic approach to developing a continuous quality improvement system that has the complimentary advantage of combining regulatory compliance with value-driven financial performance, please review the white paper that I drafted with colleague Nathan Ives of StraegyDriven Consulting, Aligning Healthcare Organizations: Lessons in Improved Quality and Efficiency from the Nuclear Power Industry.


Update: Hospital Readmissions

Hospital Readmissions continues to be a driving topic of concern, debate and contention in the healthcare industry.  It also continues to be an area of great interest for potential partnerships between acute and post-acute care organizations.  Whether that interest is warranted based upon expected improvement in outcomes and cost reductions remains to be seen.

JAMA Study: Assessing Program Risk
On Tuesday of this week the Journal of the American Medical Association published a study, which looked at the relationship between risk-adjusted mortality and 30-day hospital readmissions.  The reasons for testing this relationship are because of concern that artificial incentives will drive behaviors with unintended consequences.

First, the concern is that hospitals may invest resources to lower readmissions for targeted conditions at the expense of quality care for other conditions.  Second, there is concern that patients may not cared for in an environment that is determined by clinical needs and requirements, but instead by financial considerations.  For those who believe these concern are overstated the results of this research will serve to reinforce their perception. 

Data was analyzed for Medicare beneficiaries admitted to hospitals between July 2005 and June 2008 with a heart attack, heart failure and pneumonia. These are the three conditions hospitals are now being penalized for 30-day readmissions under the Medicare Hospital Readmissions Reduction ProgramAccording to the study, “risk-standardized mortality rates and readmission rates were not associated for patients admitted with an acute myocardial infarction or pneumonia and were only weakly associated, within a certain range, for patients admitted with heart failure.”

RWJ Foundation: Revolving Door
Another report released this week, by the Ro
bert Wood Johnson Foundation, found that hospitals and their partner relationships made little progress from 2008 to 2010 at reducing hospital readmissions for elderly patients.  Using new Medicare data from the Dartmouth Atlas Project, researchers found , “one in eight Medicare patients were readmitted to the hospital within 30 days of being released after surgery in 2010, while one in six patients returned to the hospital within a month of leaving the hospital after receiving medical care. Patients were not significantly less likely to be readmitted in 2010 than in 2008.”

The report also shares findings from interviews with patients and providers that sought to better understand the root causes of patient readmissions.  While some portion of those readmissions were either anticipated or necessary, there were also a significant number of readmissions that could primarily be attributed to non-clinical considerations, such as discharge planning, the individual’s support system, care coordination and the availability of primary care post-discharge.

So what to make of this? Research is continuing to support the hypothesis that cost savings are achievable by creating better alignment of care requirements and care settings without sacrificing quality.  The ways in which providers achieve such savings, however, are no clearer today than they were several years ago.  Also up for debate is whether the Hospital Readmissions Reduction Program is providing a meaningful incentive to drive innovation – or whether providers are reacting to market realities (likely some combination thereof).

What does not seem to be up for debate is the reality that proactive healthcare providers are pushing integrated delivery models that seek to facilitate better resource alignment.  Are you one of those organizations?


Acute & Post-Acute/Long Term Care: How to Have That Difficult Conversation

We’ve all experienced times in our lives when we have to face a difficult conversation and the angst with which we anticipate its completion.  An example might be the nervousness and anxiety of approaching someone to whom we are romantically attracted.  Another example would be the dread and sorrow of approaching someone with news we know will devastate them.  More relevant to my purpose here are the myriad types of challenging but routine conversations that fall well within those two extremes.

In particular, I am referring to the conversations that are now beginning to take on a true sense of importance and urgency between leadership teams at acute care organizations and post-acute/long-term care (PA/LTC) organizations.  Whether driven by regulatory influence (e.g., the Hospital Readmission Reductions Program), new payment models (e.g., bundling pilots), cost containment initiatives or wanting to truly develop a full continuum of care, hospital administrators are getting earnestly engaged in wanting to understand how PA/LTC providers can help them reduce average length of stay and avoidable readmissions.

For healthcare organizations used to operating in silos, discussing subjects like strategic objectives, market positioning and perceived organizational strengths and weaknesses with other healthcare providers – let alone non like-kind providers – can be a most uncomfortable experience.  And that discomfort can cause such discussions to be entirely unproductive.  Time-wasting in today’s healthcare environment will not only put an organization at a competitive disadvantage – it is a short and narrow path to economic collapse.  So the obvious challenge is how to make sure such conversations – or meetings – are both meaningful and productive. 

From what I have observed and experienced over the past couple of years as a party to a number of these leadership conversations, there are some basic, yet very important, guidelines you can follow to help ensure the time you spend is productive and of value.  I have shared these below and hope that you find them useful.

Create a Statement of Purpose
How many times have you been to a meeting where a colleague says to you under her breath, “why are we here?” A Statement of Purpose should provide a clear articulation of why you are meeting and what must absolutely be accomplished for it to be a valuable use of everyone’s time. 
For example, a Statement of Purpose might read,

We will meet on <date> for the express purpose of creating a shared understanding of the joint-venture opportunity being considered, the attendant opportunities and risks, and whether both parties have sufficient interest in pursuing the joint-venture further.  Evidence of that interest will be satisfied if the parties enter into a Letter of Intent within 30 days following the meeting.

Drill Down on Your Value Proposition
Before meeting, have a very good understanding of why a potential venture or opportunity would be of value to your organization.  Define that value nominally (i.e., put it into real numbers).  For example, know that if successful, the project will add a net cash benefit of $X annually to your organization.  It is typically difficult to quantify economic success given the level of ambiguity at the early stages of discussion, but most executives I have worked with are usually surprised at the analytical specificity achievable when they are forced to work through assumptions and parameters.  And it is the very development of those assumptions and parameters that should serve as the meeting content (see next guideline).

Avoid Meeting Until There is Something to Discuss
I had a physician colleague tell me once that thousands of great ideas are presented and discussed at lunch tables across the country every day, yet very few ever make it back to the office – let alone to the type of initiative that merits having two organizations meet to discuss.  As Ashleigh Brilliant once wrote, “Good ideas are common – what’s uncommon are people who’ll work hard enough to bring them about.”

Generating interest and enthusiasm for a good idea (e.g., a joint venture) is usually a pretty enjoyable experience, so there is the natural inclination to want to meet and share that idea.  In my personal experience – and a lesson I had to learn the hard way – this is where most often ideas go to die.  They literally get talked into submission from exuberance over the imagined benefits before they can gain any traction and the support necessary to make it past lunch.

This is why taking the time and effort to develop the business case for a proposed venture before bringing the two parties together is so crucially important.  The level of detail should obviously be in sync with the desire to maintain a strong position of negotiation, but both parties must be able to understand the fundamental framework and objective reasoning that merit the time being committed by individuals attending that meeting.

Set Discussion Boundaries
Both parties should know in advance what they are willing and prepared to discuss.  As mentioned above, there ought to be a cognizant recognition that while bargaining in good faith should be a given, information is power in negotiation.  And while meeting to determine whether a potential venture merits further investment may not represent significant exposure, all too often information is exchanged without due consideration.  Of course, having a nondisclosure agreement in place is wise, and the terms and conditions will provide valuable guidance in establishing your conversational boundaries.

Have the Right People There – And Have Them Focused
With the advances made in information technology over the past decade, the ability to communicate with someone has never been easier – yet being heard has never been more challenging.  Competing for attention is one of the greatest singular obstacles to advancing organizational initiatives today.  It often requires a fair amount of dogged commitment, humility and political savvy to coordinate schedules in a way that gets the right people at the meeting in a frame of mind to concentrate on the meeting content.  But it is an effort that cannot be minimized without jeopardizing success.

Consider Using a Facilitator
Having a productive meeting often depends on the ability to stay focused on the deal points and ensuring you have the right levels of individual participation.  Personality types often dictate that level of participation, and without an objective means of balancing certain types, a few people can dominate the discussion – even if they aren’t the ones empowered to make decisions. 

Having a clearly defined agenda and a third-party facilitator that is familiar with your industry and business can add significant value.  That individual should have experience in effectively managing discussions and debate, ensuring that key concepts are introduced at just the right moments and have the ability artfully keep participants focused on the primary elements that comprise the Statement of Purpose.

Environmental trends and drivers are pushing acute and PA/LTC leadership teams to accelerate their interest in partnering on market initiatives that require collaborative efforts.  From the very beginning, the success of such initiatives depends on the ability to engage in meaningful and productive conversation.  By having the discipline and foresight to follow some basic guidelines those leadership teams can help avoid wasting valuable time.



IOM Report on Mental Health & Substance Use in Older Adults

The Institute of Medicine yesterday issued a new report, The Mental Health and Substance Use Workforce for Older Adults.  It provides the results of a study commissioned by the Department of Health and Human Services, as directed by Congress, examining the emerging and projected crisis our nation faces as a result of an insufficient geriatric healthcare workforce – specifically the capacity of that workforce to address caregiving needs resulting from behavioral/mental health conditions and substance abuse in the senior population.

It is estimated that one in five older adults in this country have one or more mental health/substance use (MH/SU) conditions.  And these conditions typically exist in individuals that also have other health problems, making diagnoses, treatment and long-term care all the more challenging.  The most common of these conditions include depressive disorders and dementia-related behavioral and psychiatric symptoms.

But substance abuse is a substantial and growing problem as well.  According to a 2009 report from the National Survey on Drug Use and Health – published by the Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA) – it has been predicted that by the year 2020, the number of persons needing treatment for a substance abuse disorder will double among persons aged 50 and older.  Unfortunately, that growth is above the linear projection owing simply to aging demographics.

Currently, however, the number of direct caregivers at varying levels of experience and responsibilities reflect the lack of historical investment in Geriatric MH/SU training and education.  As identified in the IOM report based upon their research, future caregivers will need to have expertise in the following areas:
     systematic outreach and diagnosis,
     patient and family education and self-management
     provider accountability for outcomes and
     close follow-up and monitoring to prevent relapse.

The report was also resoundingly critical of several federal agencies.  The Centers of Medicare and Medicaid Services (CMS), the Health Resources Services Administration (HRSA), SAMHSA and the National Institutes of Health (NIH) were all criticized for their failure to use their public policy influence to encourage and direct investments in workforce training in this critically underserved area.

The IOM encouraged Congress (which includes the Republican held House that again today apparently had nothing better to do than vote – what is it now, the 31st time? – to symbolically repeal the Affordable Care Act) to fund the National Health Care Workforce Commission established under that Act.  The report noted that under the Affordable Care Act, the Commission is authorized, “to serve as a national resource that focuses on evaluating and meeting the need for health care workers . . . and to build a workforce that reflects the diversity of the older adult population that it serves.”

And finally, the report provided five recommendations that together are designed to focus policy making efforts on the need for leadership, agency coordination and the accelerated development of education and training that reflects the unique needs of a senior population in need of MH/SU services and care.  In addition, the IOM believes such efforts should be directed in thematic alignment with the Affordable Care Act (i.e., being able to evidence the relative value of investments in this area of need).

What will come of this? Well, we know it’s certainly not an ideal environment to be lobbying for new expenditures, even when/if those investments were theoretically already initiated through the Affordable Care Act.  And pragmatically, it seems reasonable to assume that the House is not likely to fund the National Health Care Workforce Commission any time soon.  And we also know that as 32 million new Americans come on line with healthcare coverage (whether through Medicaid expansion or insurance exchanges) the demands of the primary care workforce will grow substantially.

But the senior population in need of MH/SU caregiving have several distinct advantages over the younger generation driving primary care investments: namely, a great deal more wealth, better insurance and a dominant voting bloc.  So while in the short run governmental funding of workforce investments may not be able to meet the projected demand for MH/SU services and care, private investment – whether from nonprofit or for profit organizations – could be richly rewarded.

And as a practical reality, those organizations that provide post-acute and long-term care to seniors are already sharply aware of the need for MH/SU as a core element of their overall approach to achieving better outcomes.  As we continue along the path toward integrated care delivery models, the inclusion of MH/SU will have to be developed and provided as a matter of necessity to achieve relatively better outcomes than competitive providers.  Knowing (accepting) that reality should be sufficient incentive to drive private investment in workforce training and education, irrespective of public policy initiatives.  The challenge will be in figuring out how to do it in a way that achieves the requisite return on investment.

  ~ Sparky

Pub Chat No. 2: Mark Testa ~ The Data-Driven Future of Healthcare

In this second installment of Pub Chat I am posting an interview with Mark Testa, the Vice President of Quality & Analytics at Catholic Health Services in Miami, Florida.  Mark is a Six Sigma Master Black Belt trained at Motorola and now responsible for planning, designing and implementing quality and process improvement strategies at CHS.

With or without last week’s SCOTUS decision to uphold the Affordable Care Act the healthcare industry – including post-acute/long-term care providers – has been steadily seeking to make greater use of Lean and Six Sigma methodologies in quality and performance improvement.  There are a lot of talking heads out there running around promoting the future of, “Data-Driven Healthcare.” Frankly, I don’t think many of them understand what that really means – and this is an area where having a little bit of knowledge may be more detrimental than continued ignorance if bad resource investment choices are made.

So I thought it would be helpful to provide some basic understanding of these concepts, as well as several suggested resources where you can learn more about quality and performance improvement in healthcare.  I hope you enjoy the interview, which you can listen to by clicking on Larry’s microphone, below:

  ~ Sparky

Recommended resources to learn more about Quality, Performance Improvement and the applicability of Six Sigma principles to Healthcare:
ASQ ~ Lean and Lean Six Sigma in Healthcare
Quality Digest
Lean-Six Sigma for Healthcare: A … Guide to Improving Cost and Throughput
Six Sigma in Healthcare: Today and Tomorrow (HIMSS)

Consumer-Driven Senior Care

In a recent article published in Beckers Hospital Review:   6 Trends in an Era of Consumer-Driven Healthcare, hospital executives were provided with the strategic implications of current and emerging trends in consumerism.  These same trends will undoubtedly impact organizations that provide senior housing, aging services and post-acute/long-term care.  Understanding, analyzing and developing strategies to address the challenges and benefits from opportunities presented by/offered as the Baby Boomer generation begins to hold sway over the healthcare delivery system will be important for both providers, as well as policymakers.  So I thought it might be useful to try and interpret the key themes presented in that article from the perspective of senior housing and care (SHC) organizations.

Key Trend 1: Transparency
The Affordable Care Act specifically focuses on two areas of transparency: the gathering, assembly, analysis and reporting of clinical and operational data by healthcare providers (e.g., provisions found in the Elder Justice Act ~ Sec. 6703 of the Affordable Care Act); and the assimilation of comparative cost/benefit – i.e., value – information and analysis, particularly relating to provider charges and third-party reimbursement of same (e.g., Health Insurance Exchanges).

With or without the constitutionality of the Affordable Care Act, the message here for SHC providers is quite simple: get used to it.  Nay, if you want to be around in another decade, embrace it.  We are accelerating toward a period of time during which provider culture will be predominantly impacted by data-driven marketing, clinical performance, operational efficiency and financial reality.  And the watchdog enforcing voluntary compliance will not be CMS, state governments or private accreditation: it will be your own stakeholders and constituents.

Key Trend 2: Social Media
People talk – and, of course, people with more time on their hands talk more.  Evidenced by the well-documented social mobilization of the 1960s and 1970s – Boomers know how to communicate.  The intriguing, albeit sometimes almost depressing, realities of electronic social networking offer a challenging conundrum to SHC organizations.  Many, if not most, healthcare providers have embraced that reality in one form or another – whether that’s physicians communicating with patients via e-mail, hospitals using online YouTube videos to promote post-discharge wellness education or organizations like MorseLife in Florida developing an iPhone app (the MorseLife All) that connects seniors in its market to their campus.

Connecting in real time, however, carries with it a variety of challenges and opportunities.  The clinical side of healthcare (the side that can save your life) requires a keen sense of discipline and objectivity – two elements largely vacant in much of social media.  But there seems to be very little standing in the way of information – and misinformation – being haphazardly propagated as proxy for clinical expertise via such media.  Consumers recognize this risk, and that will offer an opportunity for SHC providers to be positioned within social media based upon their credibility, expertise and authority.  Recognizing this has important implications for brand management.

Key Trend 3: Consumer Empowerment
The underlying objective of increased transparency, access to comparative outcome analytics and evidence-based healthcare/medicine is, of course, to help position the healthcare consumer to be in a position to better advocate for their own healthcare. The benefits of such empowerment, however, will necessarily be tempered to the extent the targeted audience is unable to take full advantage. As we know, this is often true of a senior population that may face a variety of obstacles (e.g., mobility outside the home, effects of medication, propensity toward dementia). For good or ill, it will likely fall upon SHC organizations to play a proactive advocacy role for many disenfranchised seniors.

And this will put those providers in a potentially perilous position. Being an advocate usually necessitates having a healthy dose of skepticism. It is difficult, at best, to challenge and defend at the same time. It is sort of like playing a game against yourself: you will always win – and lose. But that is what innovation is all about – finding value-added solutions where none were thought to exist. Those organizations that develop innovative approaches to consumer advocacy for the senior population in ways that add value to all stakeholders will find huge competitive advantages in the future.

Key Trend 4: Consumer Expectations
Much has been written regarding the comparative demands of the Boomer Generation relative to previous generations, but demographically we have really only begun to see this manifested where product and service offerings target the 55 – 65 age cohort (e.g., Active Adult communities, age-defying miracle cures and, of course, Harleys).  But where those Boomer consumers have begun to make their mark the evidence of their purchasing sophistication and discernment is compelling.

Boomers demand value.  And as written in this space before, value in healthcare must be understood as providing better patient experiences and outcomes at an overall lower aggregate cost.  So while value is emerging as the driving force of third-party payer expectations (whether that is from employers, private insurers or Medicare/Medicaid), it will also be the driving force of the empowered consumer.  The message for SHC providers is clear: think value first, often and always.

Key Trend 5: Consumer Outreach
The proliferation of electronic communication media offers some very compelling opportunities for SHC providers to “connect” with their targeted markets.  In doing so, however, it is important to recognize how many other sources are competing for the attention of individuals in those markets.  While I recognized that at a theoretical level, this blog has been a firsthand experience of having to reconcile your individual perceptions on the value of content produced with the actual level of interest generated.

As I have been making the point in presentations on Healthcare Reform, if we get everything else right – increasing access, improving affordability, bending the cost curve, expanding the caregiving labor force – but fail to improve upon the overall health and wellness of our society, we will have failed miserably in creating a healthcare delivery system that is sustainable.  SHC providers are very uniquely positioned to leverage the benefits and advantages that electronic media can offer to help improve the overall health and wellness of the senior population in their communities.  And such efforts will find great synergy with other strategic efforts to develop integrated care and home and community-based delivery models.

I think SHC providers have more to gain than lose by being proactive in embracing Consumer-Driven Healthcare.  What do you think?

  ~ Sparky