Helping Healthcare Makes Sense

All healthcare facilities are required by the Emergency Medical Treatment & Labor Act of 1986 (EMTALA) to any person requiring medical treatment to stabilize their current condition. Beyond that point a for profit facility can discharge and refer to the county facility or your personal healthcare provider. A non-profit facility traditionally would keep you, if inpatient criteria is met. This is because non-profits are charged under the 501(c) (3) tax status to invest in the community health needs, provide financial assistance, charity, and provide reasonable self pay rates.  For-profit facilities have shareholders that expect a return on their investment in the organization. This is not to say that one is better than the other or one provides better services, the organizational structure is just different. While for-profit facilities provides jobs that contribute directly back to the local economy, non-profits have a direct obligation to the communities in which the reside.

Choosing the right type of facility for your healthcare should be based on the type of care required and the specialty they provide. If the facilities are equal, selecting a non-profit facility that gives back directly to your community in outreach, immunizations, health fairs and other benefits might be the best selection to ensure the wellbeing of the local community.

The average person does not make the decision to think about healthcare insurance or the cost until there has been an event in their lives that impacts them, this can happen at an early age or later in life. Over the past decade there has been a shift to educate the everyday American on the cost of healthcare and taking preventative measures. This stems from a world wellness movement and from a political spotlight. Educating people that living a healthier lifestyle prolongs life expectancy and reduces overall cost in the long run has been a hard sale. The average individual requires a frame of reference or must experience a sentinel event to bring awareness to their life. Understanding that the cost of healthcare increases every year, there is a decision to be made. Do I spend the money now to gain access to care or do I wait until I need care to begin paying for it? The annual average in 2016 was $10,345 with health insurance and is expected to be $14,944 in 2023. This is for an individual in reasonably good health and not having in major events throughout the year. Match this against the average savings of an individual who is age 18 to 24, who on average has less than $1,000.00 in savings. The average cost of a senior citizen in reasonably good health is $18,424 with insurance coverage. The average cost of an emergency room visit is $2,236 prior to medication purchase, that is the average cost of annual health insurance through an employer. What makes sense, now or later?  

Healthcare from the 1970’s is very different from healthcare in the 1980’s, as that of 2009 and 2019. The healthcare industry has changed in many aspects ranging from what patients are willing to accept, to the way providers and facilities are paid. In the 1970’s the HIV/AIDS epidemic took the U.S. by surprise and devastated may people’s way of life. The Heroin epidemic, what is was believed to be and how healthcare professionals responded to it. The Measles outbreak in the 1980’s because of inadequate vaccination coverage across the country. There was limited research and a large volume of best guess and trial and error in each of these national epidemics. The government and insurance providers were writing blank checks for reimbursement for services provided for poor quality of care.

In the early to mid-2000’s CMS, insurance providers and patients all made a shift to demand quality for the amount of money being paid to facilities and providers. This was the beginning of the patient experience movement. Because of technological advancements and the increase of deductibles and out-of-pocket expense patients now require move for what healthcare cost. This became the perfect way to demand better quality in care and for it to be done in a more cost-effective manner for CMS. This allowed reimbursement to be tied directly to the experience in services patients received. Much like buying a new care, if the price is the same at all dealerships customer purchase where the experience is the best.

Healthcare facilities and providers scrambled when reimbursement began being tied to what patient’s prospective was. Overnight came HCAHPS, 360 Surveys, Language of Caring, ADIET, Studer Group and several other programs surrounding patient experience. Choice has always existed but did not become a real factor until the beginning of the 21^st Century. The internet became a primary source of information and questions surrounding healthcare for both patients and providers at the same time, this provided education about care and choice. With some 88 healthcare organizations within 4.93 square-miles in the Texas Medical Center understanding choice is real, most organizations have shifted to ensuring patient experience is a top priority. Understanding that financial performance is not only driven by the quality of care provided, but by patient satisfaction and patient choice.  

Healthcare is an industry that continues to grow in many aspects and decrease in others. Understanding what healthcare requires and is about is the first step and then ensuring that you want to be a leader is the other. Healthcare is both a challenging and rewarding industry, it can conflict a person or help them to flourish. As a new leader in healthcare it’s important to be a strong listener and absorb as much information as possible. Identifying a good mentor to assist in guiding your path is also important and impactful. Many new leaders get derailed in trying to navigate the politics, pitfalls and their passion on their own. One of the first questions one must ask is are you ready and prepared to be a leader. Becoming a leader is one of the hardest roles anyone can have. Managing people consumes 50% to75% of everyday, managing performance and behavior are the two largest factors of any leader’s day. Be prepared to be fair and constant in application and practices policy and daily operations. Know and established boundaries for yourself, things like not eating lunch with the same staff members consistently, not attending social events and restricting your presents on social media. Ensuring what you do for one team member you do for all.

Research the market so you are aware of what the market has to offer for salaries and benefits. I have found that many new leaders, including new graduates, have a misconception of what the salary ranges are in the market and region. Six figure salaries do not happen out of the gate and most times not in the first five years. Ensuring an employer offers the benefits that will meet your needs is important to research.

Healthcare and the cost thereof in the United States has long plagued the everyday consumer and at times those who are financially responsible for strategizing the next wave of providing care in the most effective and efficient manner. Economist, healthcare financial professionals, elective governmental officials, providers and grassroots movements have all tried their hands at managing the skyrocketing cost of healthcare. One of the governmental approaches has been bundled payments that began in January 2013 with the Centers for Medicare and Medicaid Services (CMS). The program was designed to allow providers and facilities to partner to increase the delivery and quality of care patients receive, all while reducing the overall cost to provide this same care. Embedded within are several options to achieve these outcomes. Some of these are derived and supported by an effective EMR/EHR system, performing the lowest level of test require and able to produce both a diagnosis and develop a treatment plan, a hierarchy for imaging services, clinical and social navigators to direct and follow up on services needed while providing referrals and post discharge callbacks to ensure compliance. There are also financial incentives associated with the reduce delivery of care overall cost.

Once could say that this concept is modeled from the insurance industry surrounding risk pool. There those who will need regular services (aged population) and those who will pay into the program but will not require services and if so, not often. A prime example of this would be a patient complaining of knee pain, an MRI can reveal some of the same outcomes a CT scan could. If the diagnosis is arthritis, both scans would reveal the same outcomes. Therefore the MRI is done first because it is the lowest level of image, thereby reducing the cost of overall services. Because there is a $3,000.00 difference, the provider would not be eligible for additional compensation based on the bundled payment allowances. Another example is that hospitals and healthcare providers determine a flat fee the provide will be paid for performing designated services and the hospital bills for reimbursement. The provider would be paid the facility and not bill the insurance.

While the bundled payment approach is a viable program, it does not go without the need for check and balances. The readmission process was tied to the program to ensure that quality care is being provided. Depending on the diagnosis, the readmission time frame ranges from 30 to 45 days for non-life threatening conditions and diagnosis. The lines of communications must remain open between CMS, facilities and providers to ensure the effectiveness of the program.

Patient engagement is a moving target that can be a challenge to nail down. While HCAPS has defined data points, there are many variables that impact the outcomes of them. The patient’s conditions, how engaged family is in the patients care, if at all, how well the unit or department is staffed, what equipment is available or broken, what quarter of the year it is and what organizations finances statements looks like. Things as simple as if the patient is on time and if the coffee is still hot. Many organizations are taking the same approach as Chick-fil-A and Disney. While these approaches work well, one must remember the nature of those business and a healthcare provider.

 Improving patient engagement can be accomplished with some simple operational changes and with the right team. From an operational perspective, having someone at the front door to greet and guide the patients at time of presentation helps to set the tone of the encounter. Way-finding items like signs, floor insignia or banners prevent patients and visitors from getting lost a great deal of the time. Having a clean lobby and waiting areas elevates questions surrounding quality and skill. Staff that presents with a smile and warm greetings who speak with clarity and present as knowledgeable reduces questions. Asking patients questions surrounding what they know and understand about why they are there and what outcomes they are looking for ensures all parties are working towards the same goals. Finding ways to incorporate healthcare into their current lives opposed to inserting their lives into their care. Having a system that allows for payment plans to be made, all the while the integrated credit report and propensity to pay program is running in the background. All of these things shows patients that providers are their for their whole well being and it opens the door for them to be engaged in their care.   

Thanks for joining me!

Good company in a journey makes the way seem shorter. — Izaak Walton