8 Things CFOs Must Know About Health Reform

Whether a Chief Financial Officer is running the fiscal operations of a hospital system, an insurance company or a company that simply employs individuals with health coverage, the decision-making process for sustainability is changing at a rapid pace. However, after years of hearing about reformation in the health system, broad, sweeping and revolutionary changes are finally happening. Major shifts are also occurring in the population, as well as technological advances that will disrupt the entire premise of a four-walled institution for care and the very model we use for health delivery.

Health care in the US is a business – a multi-billion dollar business – and understanding the financial implications of health reform will make or break every CFO. Knowing that health access, demand, quality and payment changes are inevitable there is an immediate need for CFOs across the ecosystems to embrace and plan for transformation.

1. You have too many beds.
   While many hospital leaders won’t accept this at face value due to lengthy wait times, surgical demands and desire to shift beds, the truth is there are too many beds in a lot of hospitals. Between transferals to the outpatient setting and telemedicine, the need for expensive inpatient beds is declining. Additionally, hospital leadership are increasingly finding that they face problems with state authorities when they apply to move beds. Most recently at the University of Chicago, where 338 beds were being used for a 304-person utilization pattern, the state rejected a University application to move surgical beds.
2. Food, housing and transportation of patients is your problem.
   As Americans begin to define and attempt to tackle community and population-based care, the access individuals have to quality food, affordable housing and efficient transit matter.  No one living in a food desert will have the same health outcomes as someone living next door to a Whole Foods, just as an individual with a new car will always be more consistent in making appointments and picking up prescriptions than someone who has to access three public transit buses for the same activities. Real patient engagement and activation begins with understanding the environment of each patient.
3. Your patient demographics are shifting, and so too should your leaderships. As the US continues to brown, hospital leadership must be representative of the population to understand and meet need. At a recent Modern Healthcare Top 25 Minority Executives session, an awardee remarked that the United States is now a country of minorities, and “our leadership as minorities is our future for health outcomes.” With this in mind, it is inevitable and paramount to success that the leadership of any organization resembles and represents those it serves, so it makes the financial investments and decisions that influence the community.
4. More bodies in beds will never work again.
   Value-based purchasing means that a warm body in a bed not only drives costs higher for the payer, but that the longer a patient remains in the hospital – or the more often they return – the more penalties that accrue. Therefore, the goal should not be for more bodies, but for cost-effective bodies. Depending on the community serviced, this can mean desire for more Masters Athletes, specialized services or elective services. Additionally, as we shift to a world where technology enables more clinical procedures and recovery to be done in the outpatient setting, or at home, and expensive inpatient procedures decrease in volume and reimbursements, hoping to fill beds is futile.
5. Alignment with physicians is nonnegotiable.
   No leader can effectively attain a goal without buy in from those who carry out the work.  However, it is important to be aware that “physician alignment” is a term that causes almost all physicians to turn and walk the other direction out of fear that this indicates buying their autonomy and dictating their day-to-day, moment-to-moment ability to practice. According to Healthcare Financial News the implications of physician behavior are so important in 2014 that more revenue than ever will be spent recruiting physicians who see the world the same way you do, which is not very different from how corporation CFOs think about their employee hires.
6. As consumers take on more and more pay responsibility, unexpected payment shifts will keep occurring.
   Many experts estimate that defined contribution, health insurance exchanges and the growing individual health insurance market means that patients will become more informed about spending their health care dollars, and therefore, more unwilling to spend. The future of reimbursements and pricing strategies is presently a puzzle wrapped in an enigma because of extreme uncertainty. However, it is general knowledge that Medicare and Medicaid reimbursements are going to continue decreasing, with the American Hospital Association and Moody’s already estimating an, “unequivocally negative” outlook for hospitals on the reimbursement fronts.
7. Technology and data utilization can save you money.
   While the learning curve with new technology can be excruciating and the meaningful utilization of collected information seems daunting, everything from workflow to health activities and employee/patient engagement can be monitored – and altered in real time – using new technology. Moreover, the more information that is known today, the better predictive analytics and behavioral change that can be made tomorrow. However, as the amount of technology available to leadership continues to grow exponentially, the purchasing of new tech will be a balancing act between what is a passing fad versus what is sustainable and transferable.
8. Your EHR is going to cost you. Big time.
   Now this seems obvious to most hospital CFOs, as they have already seen the initial price tags that come with implementing a “holistic” electronic system. However, the most costly elements may not yet be realized. As mergers and acquisitions continue, technology advances and EHR capabilities increase, the need to refresh systems will continue.  At present there is not one system that meets end-to-end patient or provider needs, leaving the ecosystem open for further disruption, which inherently includes more interoperability, more upgrades, more plugins and more costs.

 

10 Things Hospital Leadership Need To Know About Social Media And Marketing

Building any brand can be difficult, but in the US, hospital identity and branding are paramount to success within a community. By listening to patients, getting feedback on wants and needs, engaging individuals and creating new incentives, a better reputation, greater trust and improved health outcomes can all be achieved.

Below are 10 things hospital leadership should keep in mind when thinking about marketing and strategy in 2014 and beyond. 

1. In 2013, it was estimated that 62% of emails were opened on a mobile device. Checking email is the top mobile activity among smartphone and tablet users. More people in the world own a mobile device than a toothbrush, so using email to inform patients about new services, community events and preventative care tactics is a must.
2. The brain processes visual data 60,000 times faster than text. Additionally, 90% of information transmitted to the brain is visual. Whether it’s growing your brand identity or improving medication adherence through visual instructions, images are key to interacting with, informing and empowering patients.
3. Surprisingly, Grandparents are the fastest growing demographic on Twitter.  Not only does this indicate that it is here to stay as a social media platform, but it’s a great place to target our aging population who consume the majority of our health services.
4. In 2014, more than 50% of Internet users, or 102.5 million people in the US, will redeem a digital coupon. There are many new partnerships with retail clinics, pharma companies and other service providers that can use coupon-like strategies for patient cost-savings and adherence.
5. The number of devices connected to the Internet now exceeds the number of humans on earth.  So don’t forget to market on multiple platforms and for many different devices. Top sites include Twitter, Facebook, Pinterest and Instagram.
6. Social media influences 93% of shoppers final purchase decisions. Further, 90% of consumers indicate that they trust peer recommendations. Therefore, previous patients are your greatest allies. Their reviews online matter more than you think.
7. More than 78% of US Internet users research products and services online, and every month, there are more than 10.3 billion Google searches, with most people clicking one of the top four links. What your top hits say about your organization, your providers and your quality of care can influence your bottom line.
8. Targeted, content marketing costs 62% less than traditional marketing, and, per dollar spent generates about 3 times as many leads. When creating a marketing strategy for a particular service line, service, or physician group, think about exactly who needs to see what ad and what information they will be looking for.
9. Consumers that receive email newsletters from companies spend 82% more with those companies. Think about what that says for brand loyalty following engagement, and about the ability of constant, relevant engagement. Patients are consumers, and like email, newsletters keep them informed.
10. 70% of people surveyed claim they would rather learn about a hospital or company through articles rather than direct advertisements. Therefore, not only are advertising campaigns important, but so are the patient experience testimonies, community reviews and Forbes articles that highlight the work being done inside and outside of your hospital.

 

Massachusetts Wins the Prize for Most Expensive Healthcare

It has recently been brought to the attention of the good citizens of Massachusetts that we spend more than anybody else on healthcare.  According to the Massachusetts Health Policy Commission report published recently, Massachusetts spends 16.6% of it’s economy on healthcare, as opposed to the national average of 15%.  The expense is in both higher utilization and higher prices.  It is across all payer types.  The most cost is associated with hospital care and long-term care/home health care.  The report goes on for many pages with reference to lots of charts and graphs.  I cannot pretend to understand all of it, and I defer to Dr. Paul Levy, who knows a lot more about this sort of thing than I do, in a post he recently wrote for The Health Care Blog (http://thehealthcareblog.com/blog/2014/01/09/the-data-are-wrong-our-patients-are-sicker/).  The best I might be able to do is to de-code some of the language in the Executive Summary.  To wit:

1. “Significant trends are occurring in the provider and payer market. For providers, the delivery system is growing increasingly concentrated in several large systems, with a larger proportion of discharges occurring from major teaching hospitals and hospitals in their system.”

Partners and Caregroup, along with a couple of for-profits, have eaten up pretty much all the formerly-independent hospital systems and physician practices.  While this means they can negotiate more effectively with vendors, it does not mean that potential cost savings gets passed on to anybody below the CEOs.

2. “…many provider organizations seek to re-orient care delivery around patient-centered, accountable care models, though significant challenges such as misaligned payment incentives, persistent barriers to behavioral health integration, and limited data and resources remain.”

This is nice-speak for “A lot of groups are moving toward accountable care organizations, without any real evidence that care in this model is better or that it’s any cheaper.”

3. “In addition, public and commercial payers are increasingly developing alternative payment methods that aim to alter supply-side incentives. However, there are significant challenges in implementation, including wide variation in these types of contracts covering Massachusetts providers, both within and across payers, as budget levels, risk adjustments, and other terms are negotiated.”

Everybody has a different deal.  Everything can be negotiated.

4. “The operating expenses that hospitals incur for inpatient care differ by thousands of dollars per discharge, even after adjusting for regional wages and the complexity of care provided. Some hospitals deliver high-quality care with lower operating expenses, while many higher-expense hospitals achieve lower quality performance.  Operating expenses are driven in part by market dynamics. Hospitals that are able to negotiate high commercial rates have high operating expenses and cover losses they may experience on public payer business with income from their higher commercial revenue, while hospitals with more limited revenue must maintain lower expenses.”

Operating expenses make no sense.  There is no consistency.  Going to a big fancy hospital with a big fancy name does not mean the care you get will be better, but it will likely be more expensive because the fancy hospital also has things that make a lot of money, like imaging machines and advanced non-invasive procedures.

5. “An estimated 21 to 39 percent ($14.7 to $26.9 billion in 2012) of health care expenditures in Massachusetts could be considered wasteful.”

No translation needed.  I could give you a hundred examples of waste right now, but anecdotal evidence is not data.  Massachusetts HPC has the data.

6. “Persistently high-cost patients – those who remain high-cost over multiple years – are easier to identify for care improvement and better health outcomes. These patients represent 29 percent of high-cost patients and make up 15 to 20 percent of Medicare and commercial spending in Massachusetts. Interventions that have been shown to improve the efficiency of care for high-cost patients include: prevention of conditions that often lead to expensive health crises; process and operational improvements that reduce the cost of episodes that are common among high-cost patients; and care management resources to support patients to manage their care more effectively and better coordinate care for patients across multiple provider settings.”

We know who the highest cost patients are and if we had better ways of encouraging prevention, managing diseases so they don’t get out of hand, and helping people take care of themselves in the community, we’d spend less.  Maybe.

So there you go!  Maybe these things can be addressed, maybe they can’t.  In the meantime, save your pennies, Massachusetts residents.  You’re gonna need them.

 

Health IT Thrives With New Startup Companies

As the health insurance exchanges opened for enrollment just days ago, the federal government, including the President and the Department of Health and Human Services (HHS), had to acknowledge that it was not technologically ready. The IT infrastructures by which individuals tried to sign up for health insurance crashed and were unavailable throughout the first day and the weeks after. Those same sights were supposed to track enrollment, but proved to not be as well tested and far more expensive than originally anticipated. However, despite the shortages and disappointments with government IT readiness for exchange websites, there was a surge in US-based startup companies that demonstrated just how innovative and forward thinking technology can be in the health care arena. Nine new companies, all curated through BluePrint Health were introduced at that same time three weeks ago on “Demo Day,” and were ready to show the new frontier of health care, and how to transform care delivery through technology.

Health IT Incubators Driving Innovation

Blueprint Health is an accelerator program geared towards health care companies that want an intensive three-month mentorship to help find customers and capital, and learn from leading industry experts. The companies that are selected for the program range from individuals with a clever value proposition to well-established organization leaders that have existing customers, investors and are generating significant revenue, but with new ideas. According to Doug Hayes, a Principal at BluePrint Health, “We are seeing an acute need for innovation at the seed stage of the health care ecosystem. With top-down changes in regulations and quickly shifting incentive structures, the most successful companies will be those who can nimbly adapt.”

He asserts that what makes BluePrint successful is that it is, “uniquely positioned to attract, identify, and support the entrepreneurs that fill the gaps of service left in the wake of massive industry changes.” The accelerator program promotes the mindset that new businesses should not have to focus exclusively on fundraising. Hayes says, “Building a company is extremely difficult, and a founders’ time is best spent on customer and product development, not fundraising.” With that mentality, BluePrint does not use many pre-established filters when evaluating the near 1,000 applications it receives each year, but instead concentrates on business models.

The nine particular startup companies that were cultivated during the summer of 2013 range from Healthify, which focuses on creating platforms that connect and standardize medical homes to treat social needs to Board Vitals, an organization that improves the testing system of our nation’s providers. Each of these new businesses gives hope to innovators and entrepreneurs.

The Companies

Artemis

Artemis is a health care analytics firm specializing in benefit claims. With employers spending billions of dollars on health care, benefits managers need more information than the historical, once a year paper reports of the past. With the Artemis platform, benefit managers have graphical, real-time updates for claims and assessments. The creators claim that that deploying its tactics not only saves money for organizations, but also heads off future costs through prevention and determination of key cost drivers.

Board Vitals

Board Vitals brings together publishers, universities, and top physicians into a single digital platform for medical specialty education, with pass rates that are 10% higher than the national average. According to co-founder, Dan Lambert, “Content is continually voted up and down, meaning that the very best material comes to the top and outdated or incorrect content is voted out.” His partner, Andrea Paul added that their aggressive, but attainable, goal is to have materials for 20 of the 35 specialties in 2014.

CredSimple

The founders of CredSimple created a system to make the mandatory credentialing of physicians cheaper and more efficient. According to co-founder Garry Choy, at present, credentialing takes two to three months per physician and hospitals spend millions a year on the routine, but inefficient process. CredSimple uses an impressive 214 data sources to verify credentials, saving all provider parties time and resources, with downstream positive implications for entire hospital systems.

Genterpret

Pharmaceutical companies strive to gain pricing power and market share using genetic information about how patients respond to drugs. Genterpret, started by two system biology PhDs, links genetics to drug responses in one-third of the time (six months) of previous genetic testers. The faster turn-around time and vast outreach program created by the founders suggests that the Genterpret technology can soon be applied to thousands of diseases, improving health outcomes and saving money.

Healthify

After years of working in Baltimore health clinics, the creators of Healthify joined forces to start a company that addresses social needs such as food insecurities to improve health in communities. Medicaid spending on medical homes averages about $15 billion, much of which is spent on social needs. The data collected by Healthify will become vital as medical homes and accountable care organizations begin to address social needs as integral to overall health and well being.

ReferBright

ReferBright helps health practitioners with digital marketing in a world full of medical advertisements. The goal, according to the founders, is to improve outreach and referral rates for various kinds of professionals. Additionally, the automated system makes updating personal information easy for practitioners and makes vetting of practitioners easy for hospitals, knowing the information on ReferBright has been inspected and verified.

SpotMe Fit

According to co-founder, Jarrod Wolf, SpotMe, “allows employers to reward their employees for attending any fitness facility, running in races, or for using fitness apps and devices. When the barrier to incentives are removed–like eliminating paperwork and providing immediate rewards–and employees are given the flexibility to choose how they engage in fitness, then program participation rates skyrocket.” This focus on wellness and fitness programs is to improve health outcomes and lower health costs through incentives, monetary and physical.

Staff Insight

The premise of Staff Insight is to increase workforce productivity, specifically through hospital leadership being able to understand and staff facilities to the optimal levels. The company aims to use real-time dashboard to identify staffing levels in units, test baseline productivity, set new benchmarks for productivity and ultimately save revenue for facilities by optimizing productivity. The founders claim that early adopters have already seen a two to four percent increase in productivity.

WellTrackOne

WellTrackOne conducts a Medicare-approved personal assessment that hospitals can use to track patient data and identify potential risk factors. To lessen the administrative burden and disruption to the workflow, WellTrackOne claims that it can integrate all electronic health records, from multiple systems to improve data and health outcomes.

The Future Of Health Technology

Despite the federal governments success in getting support from professional athletic organizations and celebrities like Jennifer Hudson, the technological infrastructure just wasn’t ready for consumer usage. In contrast, Doug Hayes says that a key reason BluePrint startups were ready on Demo Day is due to the mentor community and outreach.

He claims that a by-product of their focus on business models and portfolio is that it, “includes many enterprise solutions. The long sales cycle and disparate channels within health care makes enterprise sales an especially tough nut to crack. However, our experience within enterprise and our mentor community, 150 strong, makes us especially well positioned to help founders sell into large payers, provider networks, pharma, and other enterprise customers.

 

Primary Care Deserts Do Not Disappear With Nurse Practitioners

In coming years the US could see growing shortages in the availability of primary care physicians (PCPs). With the number of individuals seeking care increasing and the current medical system continuing to incentivize physicians to specialize, the number of available PCPs will decline proportional to the population. To fill that gap, Ezra Klein and others have asserted that expanded scope of practice will allow nurse practitioners (NPs) to serve as viable substitutes for primary care shortages.

While NPs serve a vital role in the system and meet need, the argument that they are a 1:1 substitute for PCPs (but for the greedy doctors and pesky regulations holding them back) is singular and shortsighted. The argument also fails to address broader policies that influence both NP and PCP behaviors. Policies that unjustifiably lead to the unequal distribution of caregivers, location or expertise, inherently parlay into unequal care for patients. Sadly, a broader scope than “freeing nurse practitioners” is necessary to meet primary care needs, as NPs are complements, not substitutes. Policy must address the need for more primary care and assist to realign the system to meet our country’s basic care and equality through redistribution.

Primary care is the foundation of the evolving health care system, with equal access the intended goal of the ACA. Along the way to meeting future demand for primary care, NPs can be increasingly utilized to meet the needs of Americans and improve the health of the nation. And let it be known I am a strong proponent and supporter of nurse practitioners and all non-physician providers and coordinators. However, the argument that most NPs practice in primary care and will fill the primary care gap, estimated at about 66 million Americans, is inaccurate. It isn’t a 1:1 substitute, especially given that models of the solo practitioner are vanishing in lieu of complementary and team-based care.

The US, unlike many western countries, does not actively regulate the number, type, or geographic distribution of its health workforce, deferring to market forces instead. Those market forces, however, are paired with a payment system whose incentives favor high volume, high return services rather than health or outcomes. These incentives are reflected in where hospitals steer funding for training, and in the outputs of that training.

Throughout the US there are geographic pockets that fail to attract medical professionals of all kinds, creating true primary care deserts. These deserts occur in part due to the unequal distribution of practitioners in the health care system, with our medical schools and salary opportunities producing low numbers of generalists across the board. We have even continued to see shortages in nurses throughout the US.

In fact, 2012 residency matching rates not only show continued unfilled positions in primary care, but that the rates of graduating minorities are highly skewed from programs. This contributes to even greater problems with finding primary care providers that reflect the populations they serve. Sadly, this is also true for nurse practitioners, where only 4.9% are African American, 3.7% are Asian or Pacific Islander and 2% are Hispanic. Further, the geographic distribution of NPs and physicians assistants alike is close to that of physicians. A June 2013 assessment found that the distribution for urban, rural and isolated rural frontier primary care providers is within a few percentage points for NPs and PCPs.

Ezra Klein was not wrong in his assessment that physicians are often influenced by income. However, it seems likely that financial incentives are drivers for many professionals in the health care sector, including nurse practitioners, registered nurses and physicians assistants (PAs). Dr. Andrew Bazemore, Director of the Robert Graham Center for Policy Studies in Primary Care in Washington, DC has done significant research in this area. His perspective is that, “The suggestion that runaway health system costs could be contained simply by replacing higher salaries of physicians for lower salaried substitutes with less training misses the point – that cost containment will most likely result from optimizing primary care functions such as prevention, population management, care coordination, and avoidance of unnecessary referrals, procedures, ER use and hospitalizations of primary care providers.” Dr. Bazemore asserts that, “Achieving that level of effectiveness likely involves teams that include primary care physicians, NPs, PAs, behavioral and community health workers, and other important components, operating in a transformed practice setting.”

It is also correct that regulation on NPs is onerous and sometimes oppressive. Across the nation, regulation on NPs is exceptionally disjointed and often results in unnecessary hurdles for all involved, called scope-of-practice laws. Although impediments are common in the health care system, it is extensively difficult for NPs and similar non-physicians to break into a system that is deeply rooted in tradition.

However, by honing in on one piece of the puzzle, Mr. Klein missed the bigger picture. The principals of substitution do indicate that on the supply side, NPs stepping into roles for PCPs would better meet demand. But that is not the real world outcome. The broader landscape shows us that instead of a 1:1 substitution, nurse practitioners are compliments in the overall care system, important roles that fulfill many primary care needs.

Therefore, policy changes are still needed to improve patient health outcomes and forge a team-based relationship between care providers. Incentives to enter primary care and needed across the disciplines, as are models of team-based training that build on the strengths of each in managing whole persons and populations. Ezra Klein fails to note that most primary care shortage estimates implicitly include NPs and PAs already working in primary care while not accounting for the fact that NPs and PAs are choosing specialization over primary care for the same reasons as physicians.

Instead of an environment where NPs and PCPs are positioned to compete with one another, federal and state legislators should spend more time crafting policy that equalizes the distribution of care providers across the system. That redistribution means incentivizing, monetarily or otherwise, primary care clinicians to stay in general medicine and work in tandem with other providers. Whether it be the reformation of medical school, constructing a more honest approach to population health or restructuring pay scales and incentives, team-based medicine with improved access and outcomes should be the real discussion.

 

Do Readmission Rates Really Indicate Hospital Quality?

Unplanned readmissions to the hospital have been the focus of much attention in recent years for obvious reasons: First, they are relatively easy to measure using administrative claims data. Second, like all inpatient hospitalizations, they cost a lot of money–and are therefore a target for reducing spending. Third, they are a proxy for quality of care, as at least some portion of them are likely avoidable if the hospital does its job well. On this last point, many disagree, citing the lack of continuity of care that exists post-discharge as a major source of readmissions. According to the folks in this camp, the patients themselves and their primary care physicians–not the hospital–are to blame for many of the unexpected returns to the hospital.

While this debate rages on, however, the federal government is taking action. Since 2009 they have published data on hospital quality using the Hospital Compare website, so that the public can be better informed. Then, starting last October, readmission rates for three conditions (heart attack, congestive heart failure, and pneumonia) were tracked, and hospitals with higher than expected rates were subjected to a reduction in Medicare reimbursement.

But a recent study from Matthew Press and colleagues in the June issue of Health Affairs finds that hospital readmission rates may not be such a good indicator of hospital quality after all. First, they found that across all hospitals, readmission rates for heart attack ranged from a low of 15.3% to a high of 25.6%. When they divided the hospitals up into quartiles, they found that only 1.7 percentage points separated the bottom 25% from the top 25%. Then, not surprisingly given the limited distance between the groups, they found that in just two years, many of those in the best performing group moved into the worst performing group and vice versa. Part of the explanation is what statisticians and econometricians call “regression to the mean.” In short, if you’re at the top of the pack, it is statistically more likely that you will move down than move up, just because you’ve got much more room to move in one direction than the other. The same is true in the reverse for the low performers. The investigators also found that, with few exceptions (e.g., teaching status), risk-standardized readmission rates were not correlated with other measures of hospital quality.

So what does this mean? Well, the authors suggest, there could be quite a few problems with policies that rely heavily on readmission rates alone as an indicator of hospital quality. Instead, they argue that other measures should be considered in addition to readmission rates when comparing hospital quality and that it is important to take regression to the mean into account by adjusting accordingly. In short, when it comes to measuring hospital quality, the more ways in which it is measured, the better.

 

Community Benefit: Holding Non-Profit Hospitals Accountable

With all of the recent scrutiny of Mitt Romney’s tax returns, here’s something you might not know: non-profit hospitals are exempt from paying any federal income taxes. The rationale behind this is that these hospitals deserve a break because they provide significant benefits to their communities. This community benefit can be thought of as consisting of the sum total of a number of things like the amount of uncompensated care the hospital provides, the number of lives it saves, the number of jobs it provides, and the impact it has on residents’ quality of life. If a hospital is creating jobs, restoring people’s health, saving people’s lives, and providing a health care safety net for the community, then perhaps it shouldn’t have to pay federal taxes. Similar to the case for making employer-based health insurance tax-free, this is a way for the federal government to effectively subsidize something that it considers to be beneficial to the public.

Hospitals certainly enjoy their tax exemption, but the bigger question is: Do they deserve it? For more than 40 years, the rhetoric of community benefit has been bandied about without actually defining what it includes, establishing criteria for the amount of community benefit that must be provided to merit non-profit status, or evaluating the extent to which non-profit hospitals are doing so. What has been done is research showing that more often than not, non-profit hospitals behave a lot like for-profit hospitals. And who can blame them? After all, why not take the tax break with one hand and attempt to maximize profits with the other hand? In fact, the former bolsters efforts at the latter.

Since 2009, however, the IRS has required non-profit hospitals to document the dollar amount of the community benefits they provide. In the February issue of the American Journal of Public Health, Karen Principe and colleagues consider what effect health reform may have on the provision of community benefit. For example, as more Americans are covered by insurance, the amount of uncompensated care a hospital provides can be expected to decrease. The authors report that some have called for an end to non-profit status for hospitals. One way to think about this is that the federal government would be shifting its subsidy from the hospitals to the individuals as it helped them to purchase insurance. The authors disagree, however. They argue that hospitals will still need to provide uncompensated care for individuals who move in and out of coverage, and that coverage expansions under the Affordable Care Act will strengthen the financial position of hospitals, leading hospitals to allocate community benefits differently. That is, they will provide less uncompensated care, but more of the “other” stuff that constitutes community benefit.

I like their optimism, but without strong enforcement to hold non-profit hospitals accountable, I think hospitals are about to win big: They’ll keep their tax-exempt status, provide even less uncompensated care, see their revenues increase, and laugh all the way to the bank. And who can blame them? After all, they’ve no incentive to do otherwise.

 

Four Types of Hospitals

Today I want you to try out a thought experiment with me. Imagine that you were asked to rate hospitals according to the quality of care they provide and how much the care they provide costs. Then, imagine that you were asked to select a group of hospitals that should serve as the model for all hospitals in the country. In other words, with regards to quality and cost, you are trying to identify the “best” type of hospital. Which hospital or group of hospitals would you select as the best?

Well, you might consider creating a two-by-two table that contained all the possible combinations of quality and costs. So you’d have low quality, low cost hospitals; low quality, high cost hospitals; high quality, low cost hospitals; and high quality, high cost hospitals. Clearly, high quality is preferable to low quality, right? So the first two groups are clearly not the best. And, as far as cost goes, less is more, so the best hospitals are those in the high quality, low cost group, right? Well, it depends on who’s deciding.

The government, for example, loves the idea of high quality, low cost hospitals, because they provide maximum benefit at minimum expense. Such facilities could hold the key to enormous cost savings in health care. It turns out, though, that patients actually express a preference for the high quality, high cost hospitals. This according to a recent study by Ashish Jha, John Orav, and Arnie Epstein. The authors identify different levels of nurse staffing as explaining this patient preference. They don’t come right out and say it, but it seems that above a certain point, having more nurses on staff does nothing to improve quality of outcomes, but does improve patient satisfaction. In short, American hospital patients are paying to be pampered. If insurance didn’t foot so much of the bill, I wonder how much our preferences would change.

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Hospitals No Longer Non-Profit?

Hospitals in the United States are a mix of for-profit and non-profit entities. The latter group gets a big benefit in the form of being exempt from taxation. To qualify, well, your organization has to be deemed a charitable organization, but that definition has never really been established or enforced. Consequently, hospitals are more or less on the honor system to provide a sufficient level of uncompensated care and other services that are collectively termed “community benefit.” The provision of this community benefit translates into non-profit status, which again, means exemption from taxation.

However, at least one state is cracking down on hospitals that appear to be gaming the system by enjoying the tax-exempt status of a non-profit without providing a meaningful level of community benefit. According to Bruce Jaspen, the state of Illinois has had enough. Their budget is tight, and they could use the revenue, so they rescinded the non-profit status of one hospital last year, are working to do the same with three more hospitals this year, and may eventually target more than a dozen additional hospitals across the state. It makes tremendous sense. After all, if you’re acting like a for-profit hospital, you should be treated like a for-profit hospital.

Budget issues are not unique to Illinois, and I highly doubt that non-profits behaving like for-profits are unique to Illinois either. Figuring out how to define, measure, evaluate and monitor community benefit levels in hospitals could become big business as states consider ways to generate more revenue.

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Adverse Events in Hospitals Higher than Expected

The hospital isn’t really ever a place you want to be. Granted, that’s changed a lot over the last several decades, back when hospitals were just places people went to die. Now, at least, hospitals are places many people go to get better, but they’re still dangerous. All sorts of bad things, known as “adverse events,” can happen within the walls of the hospital. You can catch a nosocomial (hospital-acquired) infection. You can take the wrong medication or too much or too little of the right medication. You can have the wrong leg amputated in surgery. You can be the wrong patient in surgery to begin with. You can develop pressure sores if you are stuck in bed for too long. You can slip and fall if you get out of bed too soon. The list goes on and on.

Identifying these adverse events, so that they may be prevented in the future, is a key aspect of improving health care quality. A recent Health Affairs article by Classen et al. compares several different methods for identifying adverse events. For the layperson, the take home message is: Adverse events are much more common than previously thought. It all depends on how attempts are made to measure them. As it turns out, the Global Trigger Tool developed by the Institute for Healthcare Improvement finds a lot more adverse events than any of the other widely used methods, including one developed by the Agency for Healthcare Research and Quality (AHRQ). What kind of difference are we talking about? Well, in a review of 795 patient records, AHRQ’s method identified 35 adverse events. The Global Trigger Tool identified 354 adverse events. That is what we in the business call “an order of magnitude.” And, compared to local hospital reporting systems that identified only 4 adverse events, we’re talking about two orders of magnitude (i.e., about a 100-fold difference). Just when you thought it was safe to go back in the water…..

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