Am I Competent?

Am I Competent? - Coming from a philosophy background, I pride myself on asking good questions. This is a question that has been echoing in the back of my head for a while: Am I a competent healthcare administrator? Moving past the simple answers (Yes, I am qualified for my job. No, I don't have the right experience or the right training), I think this is a question that should make every healthcare manager pause.

I am sure that many managers would attest to some of the following statements: I do what I think is best for the organization, I see the big picture, I have gotten positive feedback on my performance reviews, I manage the budget, I have increased volume. But are these enough? Have you ever asked yourself: Am I using the right tools? Are we stuck in a rut that I can't even see? Could we actually provide truly error-free care? What am I doing that is keeping the organization from succeeding? Am I not the right leader for my department at this time?

My hope is that these questions would motivate healthcare leaders to build their managerial toolboxes and take bold steps to make radical changes in their organizations. Good organizations can become great and even great organizations can strive to raise the bar. I am reminded of another question that motivates me: Have I done my best work yet? If your answer is yes, then it is time to retire. If your answer is no, then you are ready for the challenge and you have taken at least one step towards competence.

At What Cost

At What Cost - In August, The Commonwealth Fund (CMWF) released a report called "Seeing Red: Americans Driven to Debt by Medical Bills". In this report, CMWF claims that 37% of Americans have difficulty paying medical bills, have accrued medical debt, or both. On the surface, this appears to be quite a troubling statistic - a point the CMWF really drives home. And yet there is an underlying, and unmentioned, assumption that is driving this message: it is wrong for anyone to have any amount of medical debt. Books could be written (and I am sure some already have) on the question of whether or not healthcare is a public good that should be provided for all Americans regardless of their ability to pay. Whether it is or it isn't (and I will certainly devote future posts to this subject), the question of individual responsibility for healthcare utilization and financing is relevant.

Healthcare is a resource that people utilize at different frequencies and intensities. In this way, healthcare is like another public good, transportation. While the government provides the infrastructure for transportation (i.e. - roads and highways) and some means of transportation (buses, subways, etc.), the utilization of transportation is almost entirely paid for by individuals in direct proportion to their individual use. While it is just as important for me to get to work or the grocery store as it is for a person with less means or more means than myself, I have taken on personal debt to buy a car. Without a car, my options for utilizing transportation are practically limited, but not eliminated. We, as a society, have accepted that people will take on debt to utilize the transportation system. I am sure that many more than 37% of American adults have done the same. Furthermore, to meet transportation needs, you can choose to buy a used Honda Accord or a brand new Mercedes SUV. Both choices allow you to use the transportation system, but the level of personal financial responsibility is substantially different. This is a state of affairs with which most Americans are comfortable.

There is much more that could be said on this topic. Certainly, the comparison between healthcare and transportation breaks down at some point and the uniqueness of healthcare decisions have to be examined on their own. The point made here is that public goods are not completely financed by the government (education is another example of a public good that has multiple tiers based on the ability to pay), and thus some amount of personal financial responsibility is and should be expected.

Nun of My Business

Nun of My Business - This past week I got to hear the Superioress General of the Daughters of Charity (that is the head nun of the largest group of religious women in the world) and Sr. Carol Keehan, also a D.C. and the recently appointed President/CEO of the Catholic Health Association, speak about the role the Daughters of Charity have had and continue to have in healthcare. The Daughters are seriously committed to healthcare as a ministry of the Catholic Church and they have been doing healthcare for almost 400 years. That gives them quite a bit of credibility when it comes to sticking to the mission and evolving with the times.

Point in fact, a number of Daughters of Charity were beheaded during the French Revolution in the 1790s (and we are nervous that the OIG is tough on physician contracts!). More recently, one of the Daughter's hospitals in San Francisco was destroyed in the earthquake shortly after it was built. That was the 1906 earthquake by the way. What did the sisters do? Rebuild and keep on caring for the sick and the poor. I have to say that I am deeply moved by the sister's commitment to the mission and encouraged by their stories of adversity. Indeed, many Catholic hospitals have harrowing stories to tell from their own history.

How did the Daughters evolve with the times? Well, for the most part, the Daughters were the pioneers in healthcare, especially in America. When the military needed nurses to care for soldiers in the Civil War, it was the Daughters (and possibly other religious orders - of that I am not sure) that cared for both sides. When the settlers headed West for land and gold, it was the Daughters that founded the first hospitals West of the Mississippi and the first hospitals in Northern and Southern California.

So as we work towards the healthcare system of the future, we can bet that the Daughters of Charity will be right there at our side, leading the charge and caring for the sick and the poor.

The Cost Challenge

The Cost Challenge - There are not alot of positive trends in healthcare. The number of uninsured is increasing (at the moment). Quality is improving in the areas that are getting the most attention (CMS demonstration project, Core Measures, IHI), but still lagging in others. There is huge variation in the standard of care across the country and between racial groups. Insurance premiums increased by only single digits last year - that is sort of good news. But one of the key trends to watch is the cost of care. The cost of care just keeps on going up and I believe it is a trend that providers will have to reverse if we are going to create a healthcare system that is accessible to a majority of Americans in the future.

Cost is a very difficult problem. Almost no individual line item of cost is getting cheaper over time. Wages increase annually. Facilities become more costly to build. Technology is in constant need of refreshing. Supplies may be the one area where significant, industry-wide efforts have been made to control costs. Whether it is through group purchasing or supply chain management, we have at least been able to come up with reliable tools for managing the cost of supplies. Unfortunately, supplies are the least of the costs mentioned in this paragraph.

To further complicate the problem, there is a general sense that the industry, from a provider perspective at least, has already gone through the "easy" cost-cutting phase - streamlining the organizational chart, reducing staff to bare minimums, and being stingy with other expenses. With the new prospective payment system in the eighties and HMOs in the nineties, healthcare providers had to bring costs more in line with reimbursements. Even so, a stasis was not reached and real costs resumed their steady march upward.

This leaves us with the task of reducing costs in a system that has already had alot of the fat squeezed out of it. If the "easy" cost-cutting is done, then what is there left to do? The difficult, hard-to-see cost-cutting, obviously. I have heard from a number of sources now that there is probably about 30% waste in the healthcare system. Where is it? It is hiding in management practices that don't rely on data, process that have never been designed for efficiency, systems for care delivery that are not based on the patient, and staffing models that are not sensitive to predictable volumes. Certainly, there could be more added to this list.

There are at least two challenges for healthcare providers here. One challenge is to find the waste in the system and extract it without compromising quality care. Work smarter, not harder, as they say. But before that, providers need to come to believe that we need to reduce costs, not just for the financial health of the individual organization, but to lower the cost of healthcare across the board.