The face of healthcare is undergoing a national change.Those of us in healthcare remember several changes in medical care models over the years. At this pivotal time in healthcare delivery, medical practitioners need to consider the benefits of the new models for care. It is time to embrace and revisit the ideals of medical care with courage. Now is the time to treat patients at a dynamic, holistic level, and establish integrated protocols. Professionals must assert their expertise for best practices that lead patients to wellness, prevention and fewer hospital days.
The healthcare industry has many useful communication tools, such as electronic medical records systems to assist with instant referrals to wellness programs. Some in healthcare have been hoping for this time, but many healthcare professionals would rather see business as usual. In the new era for healthcare delivery, the fee for service system is caught in the throes of change.
The industry is now forced to keep pace with many external changes and grow with supply and demand. Changing cost and payment schedules, the changing demographics of the U.S., changing insurance reimbursement, changing government regulations, increasing levels of chronic illness and changes in ethical and moral values all have had influence on the system as a whole.
The future of healthcare involves educated medical professionals putting into practice what they have learned in their training. All professionals must strive to deliver ideal care that is more standardized and preventative. Medical professionals must learn to lead an integrated team for the best patient outcomes. This can be an overwhelming task for an entire system and professionals that think independently.
The medical community has the power and influence to empower patients and actively promote wellness and prevention. Providers are now immersed in a new culture of wellness under the new rules of the game called the Hospital Readmissions Reduction Program.
Healthcare as a Social or Economic Good
The challenges facing healthcare will require a united effort from the community, the public and the private sector. Benavides and David highlight that companies and metropolitan governments seek ways to save on insurance benefits for employees.[1] They note that the projected 2015 healthcare expense will reach $4 trillion and make up 20% of the gross domestic product (GDP). Private companies have begun several employee contests and programs over the last two decades designed to decrease costs associated with employee insurance.
There are now more initiatives for wellness programs for weight loss, smoking cessation and monetary rewards for annual checkups. The weight loss program from the city of Coppell, Texas helped employee Stephanie Tumlison lose 210 pounds. This will help reduce costly health complications from heart disease, hypertension, stroke, type 2 diabetes, sleep apnea, gallbladder disease, and other controllable risk factors. [1]
The Patient Protection and Affordable Care Act (PPACA) brought changes and challenges to the healthcare industry. The ideal social good is to provide insurance coverage for all to better control illness, promote wellness and contain costs. Healthcare is both a social good and an economic good for all when the efforts are geared toward wellness, quality and affordable access for all in society. The PPACA does not include changes for cost control or quality but is a way to address accessibility. [2]
Healthcare accessibility for all will continue to be an ethical argument in an industry with shrinking resources to provide for an aging and chronically ill population. The imposed healthcare reform is an attempt to enact basic insurance coverage for all in an environment where private business is unable or unwilling to provide healthcare insurance as an employee benefit. The PPACA also protects some with previously existing illness and allows for continued healthcare insurance for dependents until age 26.
Cost as the Most Important Healthcare Objective
Employer sponsored health insurance premiums increased nearly three times the rate of inflation in 2005. The annual premium for an employer sponsored family health insurance plan averaged near $11,000, and for single coverage averaged more than $4,000. [1]
Kaplan and Porter point out that the discrepancy between what healthcare providers charge, what is the actual reimbursement and the actual costs for healthcare are the barriers to controlling healthcare costs. They contend that the actual costs of healthcare are not calculated accurately and are based on reimbursement systems of the past. They believe that healthcare will move to adopt a system based on the direct costs of patient care, such as nurses, physicians and consumable supplies.[3] Healthcare holds a paradigm that too many costs are fixed when there is much room for savings. Also, reducing costs is not known to improve quality outcomes or create a value for patients, and expensive care is not always better care. Improving quality always reduces costs and now affects value-based payments at the end of the term under healthcare reforms.
The Centers for Medicare and Medicaid Services (CMS) is trying to defray medical costs and address quality issues. Healthcare providers remain on a fee-per-service model for reimbursement that does not always perform to standard quality measures.[2]. CMS is ushering in healthcare reform with a patient-centered medical home emphasizing access, integrated care for chronic illness management and accountable care organizations (ACOs).
The ACO is the primary care medical home for physicians, specialists, hospitals and post-acute care rehabilitative facilities working to better manage illness and control costs. The goal is to promote wellness, reduce costs, increase quality and improve access. ACOs that perform well are rewarded at the end of the annual period. [2]
In a 2011 webcast for the American Association for Respiratory Care, Lynn LeBouef, BSRC, RRT, RCP, former president and CEO of Tomball Regional Medical Center in Tomball, Texas, highlighted what the hospital had done to improve quality and reduce costs. Respiratory therapy had a direct effect on repeat admissions, reducing costs and improving quality. Tomball Medical Center began a quality improvement initiative to reduce ventilator acquired pneumonia (VAP), which accounts for increased ICU days, increased ventilator days and increased costs associated with a lengthy hospital admissions. The hospital was able to decrease VAP successfully from six cases in third quarter 2008 to one case in 2010. This represented a savings for the hospital of $240,000 per patient and improved quality.[4]
Also noted were Henry Ford Medical Center, whichsaved nearly $6 million by decreasing rates of infection, and Allegheny General Hospital, which saved $5.6 million by reducing hospital acquired infections in the CCU and MICU. Hospitals may not be reimbursed for hospital acquired infections under the new healthcare reforms. If quality is increased, length of stay is reduced, giving way to increased bed turnover. This will lead to increased admissions, a consistent bed count and consistent staffing.
Increasing quality also leads to cost improvements, revenue enhancements and improved profits under the new reforms. LeBouef noted that healthcare cost growth is unsustainable in the current arena, and a drastic change is required. Nearly 4.4 million hospital admissions in the amount of $30.8 billion in hospital costs are likely to be preventable, according to American Hospital Resources and Quality.
Integrating Healthcare
The American Lung Association (ALA) cites COPD as the third leading cause of death in the U.S. It is largely caused by smoking, industrial exposure and pollution. The ALA estimated 2010 costs to the nation for COPD at $49.9 billion, including $29.5 billion in direct health care expenditures, $8 billion in indirect morbidity costs and $12.4 billion in indirect mortality costs.[5] Health
organizations will be forced to prevent COPD exacerbations in exchange for payment for wellness with improved quality and financial transparency for annual bonuses.
Our healthcare system has the tools to promote wellness with programs for cardiopulmonary rehabilitation, asthma clinics, diabetes education, smoking cessation and weight loss. These programs are not revenue generating but have been shown to save organizations large sums of money through decreased hospitalizations for chronic illnesses. This is similar to corporate wellness programs designed to save on premiums.
We cannot afford to cut wellness programs. Healthcare teams must work to coordinate care for patients with chronic diseases to prevent hospital admissions with medical homes and accountable follow-up. Healthcare payment reform will lead to enrolling patients into wellness programs much earlier in their diagnosis instead of enrolling end-stage patients. Physician involvement and electronic medical record (EMR) systems can make communication and patient identification much more streamlined and accessible to the healthcare team. Healthcare professionals have this moment in history to change the culture of care to toward wellness and prevention that will improve future healthcare delivery.
References
- Benavides, A., & David, H. (2010). Local government wellness programs: A viable option to decrease healthcare costs and improve productivity. Public Personnel Management,39(4), 291-306.
- Realities Drive Change In Health Care Delivery. (2012). Financial Executive, 28(1), 36- 39.
- Kaplan, R. S., & Porter, M. E. (2011). How to solve the cost crisis in health care. Harvard Business Review, 89(9), 46-64.
- LeBouef, Lynn. (2011). Contributing to the Success of Their Organization – What Respiratory Therapists Must Do. http://www.aarc.org/education/webcast_central/viewer.asp?id=0112
- American Lung Association ( Feb 2011). Chronic Obstructive Pulmonary Disease (COPD) Fact Sheet. Retrieved from: http://www.lung.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html
- The Nexus of Health Reform and the Law. (2012). Financial Executive, 28(2), 50-53.
- The Future of Health Care in Northern Colorado. (2011). Northern Colorado business report, 2-8.
