Insigniam Quarterly 2014 Special Edition - Healthcare
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Transcript of Insigniam Quarterly 2014 Special Edition - Healthcare
S P E C I A L H E A LT H CA R E I S S U E 2 014
HEALTHCAREAN INNOVATION MANIFESTO
INSIGNIAM QUARTERLY’S
HEALTHCARE OVERVIEW
“In the increasingly complex healthcare marketplace of today, innovation is not a nice-to-have; it is essential for simply
surviving. At the same time, potent innovation can also be a source of
sustainable success, especially when the creativity and contributions of the people
of an enterprise are unleashed and the execution of new possibilities is reliable.”
— SCOTT W. BECKETT
LETTER
WWelcome to this special edition of Insigniam Quarterly, which focuses on today’s
global healthcare industry. While transforming healthcare means different things
in different geographies, we have found that a vast majority of the issues are
actually the same. As individual and business consumers of healthcare, we often
do not see the background forces that are radically disrupting the resources
and money available for our care. Healthcare executives know them all too
well: shifting demographics, increased incidence of noncommunicable diseases,
greater emphasis on wellness and value-based reimbursements, higher patient
involvement and accountability, etc. Together, these issues have all the makings of
a wicked, seemingly impossible problem to solve. However, when broken down,
there is a path to success that offers unprecedented opportunity.
Although we don’t have all the answers, we do know that the path starts with
innovation. Through our experiences working with healthcare organizations,
we’ve identified what we believe are critical success factors we will all need in
our back pocket on our journey to reshape the future of healthcare. What is it
to be accountable for our health? What does it take for a healthcare system to
become indispensable? How can the entire patient experience be reinvented?
Is it possible to embed innovation into an organization as a core competency?
What about creating a mindset of well-being and expanding our horizons for
access and delivery of care? Do you aspire to be a transformational leader in
healthcare? Have we put the right technology in place? Is our healthcare culture
guided by responsibility and accountability? Are your physicians integrated with
a diversity of specializations?
While overwhelming in the aggregate, we hope to help answer some of these
questions in this special issue, leading us all to a clearer vision. Consider it a
healthcare manifesto, a playbook of sorts, outlining critical success factors to keep
on your radar as we counter — and overcome — real-world, disruptive forces
occurring around us. Know that the same forces that are turning our world upside
down today, are leading us toward a better future. This is a rare moment in time.
This is our moment to transform healthcare itself.
Game on.
Shideh Sedgh Bina
Founding Partner, Insigniam
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 1
OUR TIME IS NOW
SPECIAL HEALTHCARE ISSUE 20142 INSIGNIAM QUARTERLY
12INDISPENSABILITYMake the patient an offer, and give them an
experience, they can’t refuse. 16REINVENTING THE PATIENT EXPERIENCEIf solutions begin by focusing on the patient, let
patient-centric care be your guide.
20GETTING MORE FOR LESSOutdated revenue models will cripple your returns.
The path to efficiency — and profitability — may be
simpler than you think.24
DIVERSIFIED, YET INTEGRATED SPECIALIZATIONHow a physician leadership network and a focus
on population health is putting the heart back into
healing.
FEATURES
DEFINING SUCCESSThe key to cracking
healthcare’s wicked
problems requires a
“different agenda”.
OVERVIEW04
TABLE OF CONTENTS
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 3
EDITOR-IN-CHIEF Shideh Sedgh Bina
EXECUTIVE EDITOR Nathan O. Rosenberg
CHIEF FINANCIAL OFFICER Ralph Gotto
DIRECTOR OF WORLDWIDE Karen Turner
CLIENT SERVICES [email protected]
DIRECTOR OF SPECIAL PROJECTS Alexes Fath
PUBLISHER Gordon Price Locke
EDITORIAL DIRECTOR Amy Robinson
GUEST EDITOR Liz Willding
MANAGING EDITOR Jonathan Ball
EDITORIAL CONTRIBUTOR Ira Katz
CREATIVE DIRECTOR Kyle Phelps
ASSISTANT ART DIRECTOR Emily Slack
PRODUCTION MANAGER Pedro Armstrong
IMAGING SPECIALIST John Gay
DIRECTOR, ACCOUNT SERVICES Jas Robertson
ACCOUNT SERVICE MANAGER Joan Khalaf
EDITORIAL QUERIES
750 N. Saint Paul Street
Suite 2100
Dallas, Texas 75201
www.dcustom.com
214.523.0300
For advertising information, contact Jas Robertson at
214.937.9811 or [email protected]
Insigniam Quarterly is published by D Custom, 750 N. Saint Paul Street, Ste. 2100, Dallas, Texas 75201. Copyright 2014 by Insigniam. All rights reserved. Letters to the editors may be sent to Insigniam Quarterly c/o D Custom, N. 750 Saint Paul Street, Ste. 2100, Dallas, Texas 75201. No part of this publication may be reproduced in any form or by any means without prior written permission of the publisher and Insigniam. Printed in the U.S.A. Magazine patents pending. For subscriptions, please visit www.insigniamquarterly.com.
Q U A R T E R LY
SPECIAL HEALTHCARE ISSUE | 2014
“People don’t often seek care due to the deep fear of the
complexity of the cost, and because they don’t feel we are
listening to their needs. We need to understand their reasons.”— DOUGLAS L. WOOD, M.D.
DIRECTOR OF THE CENTER FOR INNOVATION, MAYO CLINIC
MINDSET OF WELL-BEINGShifting the focus is all about engagement
NEW HORIZONSA model for the future of healthcare: Women’s College
Hospital
HEALTHCARE LEADERS, OUR TIME IS NOW“Innovation” is today’s critical objective
LEVERAGING NEW TECHNOLOGYTake technology to a personal level
TRANSFORMATIONAL LEADERSHIPFor Cone Health, “unleashing the tiger” of transfomation
begins with empowerment
HOW WELL ARE YOU FULFILLING YOUR PROMISE?Accountability is more than just lip service. It’s strategy.
IQ BOOST
Infographic: RX For Success
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ADDITIONAL FEATURES
Woman of the Year Award Congratulations to our editor-in-chief, Shideh Sedgh Bina, on being named a “Woman of the Year” by the Healthcare Businesswomen’s Association. For more on this award, visit www.insigniamquarterly.com/HBAaward
Insigniam and its publisher, D Custom, distribute this editorial magazine to share the opinions and insights of companies and their leaders on impactful global business issues. Insigniam Quarterly’s inclusion of a company or individual does not indicate that they are a client of Insigniam. Remuneration is not provided for editorial coverage. Individuals appearing in Insigniam Quarterly have done so with direct consent, or provided consent by a designated authorized agent in addition to being disclosed on the magazine’s audience and purpose.
4 INSIGNIAM QUARTERLY
DEFININGSUCCESSCracking healthcare’s wicked problems requires a “different agenda.”
BY LIZ WILLDING
SPECIAL HEALTHCARE ISSUE 2014
SPECIAL HEALTHCARE ISSUE 2014
In every respect, today’s global healthcare challenges fit the
definition of a wicked problem, essentially a moving target that
is difficult, if not impossible, to solve (see the 10 characteristics
of wicked problems in the accompanying sidebar).
At Insigniam, we believe a number of disruptive forces
are in play today that indeed make healthcare a wicked nut
to crack. Most healthcare executives are well aware of the
challenges, which start with shifting demographics resulting
in a predicted tsunami of older, more diverse patients with
chronic noncommunicable diseases. (NCDs). To counter this,
the industry is logically shifting to population health, which
demands a focus on wellness and value versus the old volumes-
based model to treat illnesses. While there is no dispute that
technology — from electronic health records to a plethora
of digital health tools — is proving to be a big part of the
solution, implementation is arduous and costly, and the real
gains expected from integration are still on the horizon. Factor
in increasingly involved patients who want to know where
their money is going, and it is enough to make any healthcare
executive’s head spin. Then there’s projected provider shortages,
increased regulation, and shrinking access to capital to contend
with.
While all of this may seem daunting and truly wicked, we
suggest that focusing on a handful of critical success factors
can facilitate reinvention and innovation despite today’s chaotic
healthcare environment. The process begins by asking hard
yet provocative questions. “What are the key variables that
leaders should have on their radar as they attempt to reinvent
healthcare? What will it take, as an industry, to turn today’s
enormous healthcare ‘cruise liner’ in the direction of wellness?
How will technology help enable patients as they assume more
responsibility for their own care?” While there are no easy
answers, Insigniam Quarterly turned to a number of industry
experts for context and insight into critical success factors for
10 of the top issues facing the healthcare industry for 2014
and beyond.
GLOBAL TRENDSIn the landmark study “Global Burden of Disease, 2010,”
healthcare leaders viewed a snapshot of key demographic
changes that are fundamentally changing healthcare delivery.
The study documented that global life expectancy for males
and females had risen more than 10 years from 1970 to 2010,
reaching a global average of 67.6 and 73.3, respectively. Even
more revealing, more deaths occurred globally at 70 years of
age or older, with 22.9 percent, almost a quarter, occurring at
80 years or older.
In contrast, the study noted that deaths from
noncommunicable diseases eclipsed those of infectious diseases
during the same time period, killing more than 35 million people
6 INSIGNIAM QUARTERLY
When Horst Rittel and Melvin M.
Webber coined the concept of
wicked problems in 1973, they were
largely talking about policy issues
— however they might as well have
been referring to modern healthcare.
OVERVIEW
SPECIAL HEALTHCARE ISSUE 20148 INSIGNIAM QUARTERLY
yearly — accounting for nearly two-thirds of the world’s
deaths. Why? According to the World Health Organization
(WHO), it’s a matter of priorities. In its “2008-2013 Action
Plan for the Global Strategy for the Prevention and Control of
Noncommunicable Diseases,” WHO reported that “NCD
prevention and control programs remain dramatically under-
funded at the national and global levels,” and noted that NCD
prevention was “currently absent from the Millennium
Development Goals,” established by the United Nations
with a target date of 2015. If allowed to go unchecked, the
report estimates that NCDs will increase by 17 percent over
the next 10 years.
While “increased longevity represents success against
infectious diseases,” says Roger
I. Glass, M.D., Ph.D., director
of the Fogarty International
Center at the National
Institutes of Health (NIH),
the pendulum has clearly
swung in the other direction.
“What are we going to do
with our aging populations
who are suffering from
diabetes, heart disease, cancer,
and other noncommunicable
conditions? It suggests a
completely different agenda.”
The irony is that the
vast majority of NCDs are
preventable and could be
reduced or eliminated through
increased patient support. In
this sense, Dr. Glass says it is
time that preventive programs
aimed at addressing lifestyle
issues catch up with scientific
advances. According to WHO,
up to 80 percent of heart disease, stroke, and Type 2 diabetes,
and more than a third of cancers, could be prevented by
eliminating shared risk factors, which include tobacco use,
unhealthy diet, physical inactivity, and harmful use of alcohol.
“The issues are the same worldwide,” says Elizabeth H.
Bradley, Ph.D., who is faculty director of the Yale Global
Health Leadership Institute. “The big question is whether
reimbursements based on services related to treating illness
versus funding preventive programs will keep up with the
demographic and epidemiological shifts resulting from
an aging population and the epidemic of obesity,” which
contributes to NCDs.
In the U.S. alone, she notes that one-third of the
population is obese, with the cost of care per patient
estimated at approximately $5,000 more per year than nonobese
patients. “This is very taxing to medical systems and executives
who are looking at the long run and struggling to deal with it.”
TURNING THE SHIPWhile reinventing healthcare is indeed a wicked problem,
a number of demonstrated critical factors can provide
healthcare executives with a path toward an elevated
likelihood of success.
“The process starts and ends
with having the patient’s best
interests in mind,” says Dr.
Bradley. “You have to frame
your products and services so
customers really want to come
to you. It boils down to putting
the customer first.” This means
looking at problems through the
patient’s eyes, becoming a partner
in their care. It is everything from
reducing wait times and billing
errors to supporting them with
wellness programs to achieve
lifestyle changes.
Adds Douglas L. Wood,
M.D., director of the Center for
Innovation at the Mayo Clinic,
it is important to approach
any problem in the context of
“transforming the way people
experience health and healthcare.”
He notes that “understanding
why people do what they do,” is the starting point. “First,
people don’t often seek care due to the deep fear of the
complexity of the cost, and because they don’t feel we are
listening to their needs. We need to understand their reasons.”
As organizations seek to innovate and reinvent themselves,
they should also be cautious not to rely on a cookie-cutter
approach, says Nathan Owen Rosenberg, Insigniam founding
partner. “It is a big mistake to copy what other enterprises
have done to innovate. The success we see in designing new
methods for value and access for patients are successful because
they have been invented — not merely copied. Sustained
“IT IS A BIG MISTAKE TO COPY WHAT OTHER ENTERPRISES HAVE DONE TO INNOVATE. THE SUCCESS WE SEE IN DESIGNING NEW METHODS FOR VALUE AND ACCESS FOR PATIENTS ARE SUCCESSFUL BECAUSE THEY HAVE BEEN INVENTED — NOT MERELY COPIED.”
OVERVIEW
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 9
innovation requires a leadership mandate for innovation,
proprietary innovation processes, and an infrastructure that
plays to the strengths and ambitions of your enterprise. And,
of course, unless changes are supported by the exisiting culture
they are rarely sustained long term.”
Ensuring that the revenue cycle is running like a well-
oiled machine is another key variable, says Jennifer Zimmer,
Insigniam partner, noting that most are archaic and rooted in
the past pay-for-services model. “This makes it difficult and
frustrating for patients because a significant touch point in their
experience is not user-friendly nor is it value-added for the
patient. Innovation is about building a revenue cycle where
each touch point enhances the patient experience and shows
added value.”
Regardless of the geography, tomorrow’s revenue cycle
must focus on value, especially to keep up with trends such
as personalized medicine, says Corinne Le Goff, president of
Roche SAS. “In oncology,” she explains, “different biologics
are often combined for treatment, but, ‘how do you bill for it?’
We need to have a system that allows for reimbursement in a
more personalized way.”
All of this begs for new business processes that keep pace
with those occurring in science. “We believe it is by bringing
the best minds around the table that you find the solution,”
Le Goff adds, “which includes partnerships with academia.”
Alex Gorsky, CEO of Johnson & Johnson, agrees, but
cautions, in a March 2013 interview with CNBC, that the way
forward will also “involve trade-offs, and participation from all
aspects of society. When you think about the aging population,
when you think about the demographics … it is hard not to
talk about healthcare in the context of the economy and the
systemic issue of how we somehow find a way to provide high
quality, affordable healthcare in a sustainable way.
“It first starts with ‘where do we think the unmet medical
needs are going to be?’” he explains. “If you look at the data,
it suggests cardiovascular disease, Type 2 diabetes, Alzheimer’s
— all are going to be cost drivers, particularly in an aging
population where there is a higher incidence rate and very
high costs are associated with them.” Part of the challenge,
Gorsky adds, “is being disciplined about where you do — and
don’t — invest.”
Because lifestyle-related conditions are front and center,
industry experts around the globe are in agreement that a big
part of the solution resides with primary care, integrated with
the specialties, to serve the needs of the whole population. In
the quest to achieve population health, “it’s about hospitals and
physicians working together,” says Dr. Bradley, with physician
leaders taking a major leadership role. She notes, however, that
CRITICAL SUCCESS FACTORS
IN HEALTHCARE DRIVING
REINVENTION AND INNOVATION,
COMPILED BY INSIGNIAM FROM
INDUSTRY DATA, INCLUDE:
INDISPENSABILITY
REINVENT PATIENT EXPERIENCE
NEW REVENUE CYCLE
DIVERSIFIED, YET INTEGRATED SPECIALIZATION
MINDSET OF WELL-BEING
NEW HORIZONS
EMBEDDED INNOVATION
LEVERAGING NEW TECHNOLOGY
TRANSFORMATIONAL LEADERSHIP
CULTURE OF RESPONSIBILITY AND ACCOUNTABILITY
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SPECIAL HEALTHCARE ISSUE 201410 INSIGNIAM QUARTERLY
“there is a lack of understanding on adaptive leadership in both
middle and upper management,” suggesting that medical and
professional leaders alike must sharpen their skills to effectively
react to the shifts that are occurring. This includes supporting
creativity and innovation within their organizations, as well as
developing the interpersonal skills needed to partner effectively
with physicians and care providers.
USING TECHNOLOGY TO ENGAGE PATIENTSInnovative use of technology also is expected to “take care
to the people,” says Patricia Abbott, R.N., Ph.D., an associate
professor at the University of Michigan School of Nursing
Office of Global Outreach. Dr. Abbott spoke about the use
of wireless technology to engage vulnerable populations at an
“Innovations for Global Health” conference hosted by U-M.
She referenced her study in inner city Baltimore that monitored
heart patients at home using mobile health (mHealth) devices.
“The mHealth intervention used wireless technology with
Bluetooth scales and blood pressure cuffs. It also used video
telephony (similar to Skype) and touchscreen computing to
deliver tailored messages, quizzes, and reminders. Within the
computer was a patient-owned personal record, which was
incredibly valuable in creating partnerships and engaging
patients in their care.”
As information technology proliferates, she stresses the
importance for the industry to create an interoperable and open
digital ecosystem, saying, “Access to, and sharing of, information
is a basic tenent for improving health, both in the U.S. and
abroad.”
This ecosystem includes payers and the private sector, who are
innovating rapidly with tools to assist people in monitoring their
own health, ultimately driving greater personal responsibility. A
big part of driving compliance can be achieved by empathizing
with patients, helping them address life issues, and rewarding
their successes. “The behavior modification concepts are global,”
says Joan Kennedy, Cigna vice president, customer health
engagement, noting that the industry is leaning toward virtual
interventions with incentives built in to reward success, which
can include everything from receiving a gift card for completing
OVERVIEW
In their 1973 treatise “Dilemmas in a General Theory of Planning,” Rittel and Webber noted that wicked problems have 10 characteristics:
Wicked problems have no definitive formulation. Formulating the problem and
the solution is essentially the same task. Each
attempt at creating a solution changes your
understanding of the problem.
Wicked problems have no stopping rule. Since you can’t define the problem in any single
way, it’s difficult to tell when it’s resolved. The
problem-solving process ends when resources
are depleted, stakeholders lose interest, or
political realities change.
Solutions to wicked problems are not true-or-false, but good-or-bad. Since there are
no unambiguous criteria for deciding if the
problem is resolved, getting all stakeholders to
agree that a resolution is “good enough” can
be a challenge, but getting to a “good enough”
resolution may be the best we can do.
There is no immediate or ultimate test of a solution to a wicked problem. Since there is
no singular description of a wicked problem,
and since the very act of intervention has at
least the potential to change what we deem to
be “the problem,” there is no one way to test the
success of the proposed resolution.
Every implemented solution to a wicked problem has consequences. Solutions
CRACKING A WICKED PROBLEM
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SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 11
a fitness goal, to lower insurance rates. “Our role is to provide
the tools and services and give credit when the member does
great things.”
In this sense, “It is very important that people are responsible
for the outcomes of their treatment,” says Le Goff. “We need to
hear their voice and understand their medical needs. They need
to be involved. If we can have a role in integrating the solution,
that is a role we can play.”
Dr. Glass agrees, noting that the most cost-effective treatments
are preventive and don’t involve traditional medical care.
“Twenty percent of the population still smokes. What can we
do to get them to stop? How do we help people with underlying
addiction issues? Better treatment of hypertension could bring
down the incidence of stroke, including limiting salt. We have
to think about incentivizing health interventions as one step
forward.”
What does a future-perfect picture of success look like? “It’s
when we’ve adapted our lifestyles and we say we can’t afford
to be obese,” says Dr. Glass. “We’re tracking ourselves to avoid
risks and consequences, because we think we have a future.”
to such problems generate waves of
consequences, and it’s impossible to know, in
advance and completely, how these waves will
eventually play out.
Wicked problems don’t have a well-described set of potential solutions. Various
stakeholders have differing views of acceptable
solutions. It’s a matter of judgment as to when
enough potential solutions have emerged and
which should be pursued.
Each wicked problem is essentially unique. There are no “classes” of solutions that can
be applied, a priori, to a specific case. Part
of the art of dealing with wicked problems is
not assuming any given solution is correct,
especially early in the investigation.
Each wicked problem can be considered a symptom of another problem. A wicked
problem is a set of interlocking issues and
constraints that change over time, embedded in
a dynamic social context. But, more importantly,
each proposed resolution of a particular
description of “a problem” should be expected to
generate its own set of unique problems.
The causes of a wicked problem can be explained in numerous ways. There are
many stakeholders who will have various
and changing ideas about what might be a
problem, what might be causing it, and how to
resolve it. There is no way to sort these different
explanations into sets of “correct/incorrect.”
The planner (designer) has no right to be wrong. Scientists are expected to formulate
hypotheses, which may or may not be
supportable by evidence. Designers don’t
have such a luxury — they’re expected to get
things right. People get hurt when planners
are “wrong.” Yet, there will always be some
condition under which planners will make errors.
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“INNOVATION IS ABOUT BUILDING A REVENUE CYCLE WHERE EACH TOUCH POINT ENHANCES THE PATIENT EXPERIENCE AND SHOWS ADDED VALUE.” - JENNIFER ZIMMER, INSIGNIAM PARTNER
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 13
INDISPENSABILITYMake the patient an offer, and give them an experience,
they can’t refuse.
BY ROBERT ITO
CONSUMER INDUSTRIES HAVE LONG KNOWN
the secret to capturing and retaining customers: offer the best
products and services for the price.
Anyone who has ever owned a luxury
vehicle no longer wants to live without
exceptional service, especially when
something goes wrong. To gain and keep
loyal customers, healthcare leaders would
do well to become equally indispensable
with patients, payers, and the community.
This means improving every aspect of
service, whether it’s in the primary
physician’s hospital, the specialist’s office,
or even the patient’s home.
“As a patient, healthcare can be very
daunting, so we’re finding ways to ease
their navigation, making sure that we
address what their expectations are,”
says William Dinsmoor, chief financial
officer of the Nebraska Medical Center,
a nationally ranked hospital in Omaha.
Technological innovation is key to that
mission; for example, the use of the
latest electronic medical record systems,
accessible along every step of the patient’s
medical journey, translates to speedier,
more efficient care. Similarly, technology
that tracks every aspect of a patient’s
care, from registration to outpatient
billing — like the Epic Systems suite of
healthcare software — can help identify
and eliminate medical redundancies, thus
driving down patient costs.
Healthcare organizations also need
to stake their claims as the go-to centers
for healthcare information, now more
than ever before. “As we experience changes in healthcare
systems, medicine is moving beyond the hospital’s four walls
and out to community settings, from
community-based organizations to tele-
health settings to retail health clinics,” says
Thomas Concannon, Ph.D., a policy
researcher at the RAND Corporation.
“Hospitals needs to be thinking about
taking the reins and trying to create and
sustain a place where stakeholders can
come together.”
Concannon believes that bidirectional
communication is essential, even if
many medical centers — academic and
research institutions, for example —
haven’t done much of it in the past. In
that spirit, creating transparency is the
obvious place to start, beginning with
clarity on pricing strategies, which today,
quite literally, are all over the map.
For instance, on average, the U.S.
spends twice as much on healthcare per
capita than other industrialized nations;
the same bypass surgery a citizen of
Switzerland receives for $17,000 will set
Americans back about $150,000. These
huge discrepancies have resulted in a
growth of so-called “medical tourism,”
where patients travel to places like
Belgium or South Korea to receive
operations at a fraction of the price that
they’d pay at home.
In this global environment, how do
American healthcare systems make
themselves competitive with their
international counterparts? How do they
BY THE NUMBERS
THE UNITED STATES HAS SIX TIMES MORE MRI MACHINES PER CAPITA THAN AUSTRALIA AND THE UNITED KINGDOM
6X
$150,000
$17,000
THE U.S. ALSO SPENDS AN AVERAGE OF TWICE AS MUCH ON HEALTHCARE PER CAPITA THAN OTHER INDUSTRIALIZED NATIONS.
AVERAGE COST OF A BYPASS SURGERY IN THE U.S. VERSUS SWITZERLAND
VS
prevent the people they serve from going to the other provider
down the block — let alone to the other provider overseas?
In other countries around the world, patients have ready
access to price lists for the procedures
offered at a hospital or clinic, a service
scarcely imaginable to most Americans.
“There’s been a lot of recent attention
to hospital pricing strategies in the
U.S.,” says Concannon. “These are
not transparent strategies. It would be
nice to see improved transparency in
inpatient stay, to see all the costs that
go into materials, labor, and residential
care.”
As more and more Americans learn
just how much less their overseas
counterparts have to pay for each
visit or procedure, there have been
increasing calls for change. A good
place to look is Canada, says Colin
Busby, senior policy analyst at the
C.D. Howe Institute, a Toronto-based think tank. There,
healthcare centers in some provinces are slowly moving from
a fee-for-service system to a more blended payment model. In
that model, family doctors are paid on a per-patient basis and
encouraged to enroll a large number of patients — basically,
the Accountable Care Organization
(ACO) model many physicians are
aiming for here. “By paying them per
patient, the incentive on a physician is to
only spend their time with their sickest
patients,” he says, “and to try to keep
everyone else healthy.”
In addition to lowering prices,
healthcare providers can also boost
their desirability by offering services
that their patients simply can’t receive
from their competition. “What we do
is provide a very high quality product,”
says Dinsmoor. “And we provide very
specialized services. We do things that
nobody else can.”
In the U.S., the drive toward more and
more advanced medical technologies is
another big reason for the country’s escalating healthcare
costs; for example, America has six times more magnetic
SPECIAL HEALTHCARE ISSUE 201414 INSIGNIAM QUARTERLY
FINDING WAYS FOR DOCTORS TO SEE PATIENTS LESS — ALBEIT BY KEEPING THEM WELL — MIGHT BE THE BEST WAY TO INCREASE PATIENT SATISFACTION.
HEALTHCARE ORGANIZATIONS ALSO NEED TO STAKE THEIR CLAIMS AS THE GO-TO CENTERS FOR HEALTHCARE INFORMATION, NOW MORE THAN EVER BEFORE.
resonance imaging (MRI) machines per capita than Australia
and the United Kingdom.
But lest one think that Dinsmoor is just playing the medical
equipment arms race — “our proton therapy treatment program
is better than yours” — that’s just one part of the picture. Those
services Dinsmoor is talking about aren’t just hinged on having
the latest, greatest medical devices, although that’s certainly a
factor. The service component is part of a larger package of
customer relations.
Central to this is the understanding that physicians and
patients are all in this thing together. “Shared responsibility
is huge,” says Dr. Carlos Jaén, chair of the University of Texas
Health Science Center at San Antonio, Family & Community
Medicine. “We’re here to be partners. If you’re ready to do it,
I’m happy to help you. But it’s up to you, really. It’s your life.”
This idea of “shared responsibility” (both in terms of taking
care of one’s own health and paying one’s fair share for services)
is one that’s built into the systems of countries like France,
Belgium, and Japan.
When patients decide to become more proactive about their
healthcare, education and wellness centers will play a key role in
the future. “I think patient education is extremely important,” says
Dinsmoor, who cites the health management program Simply
Well as a step in the right direction. “It’s a tool that employers
can use to help screen and identify opportunities to improve their
employees’ health status,” he says. “If we want to bend the cost
curve in healthcare, we’ll need to shift resources from the back
end, from the complicated intervention, to more prevention.”
Ironically, finding ways for doctors to see patients less —
albeit by keeping them well — might be the best way to increase
patient satisfaction. Nobody likes being sick, after all, no matter
how efficient or professional the care at their hospital might
be. And while patient satisfaction might be a key component,
perhaps the most important component of making a healthcare
provider indispensable to its patients and payers, getting patients
to take responsibility for their own health, is often one of the
toughest things for doctors to do.
Although some regions of the world are further along than
others, forging stronger shared responsibility is a place where
the new U.S. model, driven by the Affordable Care Act, could
well stake a claim. “That’s the challenge with the ACA:
How are the individuals going to be engaged with this?” says
Dinsmoor. “What’s their responsibility? And that’s the piece
that’s been missing. The delivery system is getting organized
to do it, but how do you get the individual engaged? There are
some people that are very engaged with it, but there are lots
of people that are not. And underlying that is education, and
taking ownership of your own health status.”
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 15
01CRITICAL SUCCESS FACTOR
Indispensability: A healthcare system must make itself indispensable with an offering that healthcare community residents, patients, and payers cannot (and will not) avoid or go around.
CLOCKWISE FROM TOP LEFT: COLIN BUSBY, SENIOR POLICY ANALYST, C.D. HOWE INSTITUTE; THOMAS CONCANNON, PH.D., POLICY RESEARCHER, THE RAND CORPORATION; DR. CARLOS JAÉN, CHAIR, THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER, UT SAN ANTONIO; WILLIAM DINSMOOR, CFO, THE NEBRASKA MEDICAL CENTER.
HEALTHCARE LEADERS
TAKING CUES FROM THE HOSPITALITY INDUSTRY,
leading healthcare organizations around the globe have been
rethinking the experience they provide to patients.
The Beryl Institute, a global community of practice and
thought leaders, supports the notion that improving the patient
experience has financial implications that reach far beyond
reimbursement dollars, performance pay, and compensation tied
to outcomes. In a recently published white paper, “The State
of Patient Experience in American Hospitals 2013: Positive
Trends and Opportunities for the Future,” the Institute cites a
2008 J.D. Power study that revealed that
hospitals scoring in the top quartile in
satisfaction had more than two times the
margin of those at the bottom. Another
sobering fact is that a satisfied patient tells
three other people about the positive
experience while a dissatisfied patient
tells up to 25 people about a less-than-
satisfactory experience. Models suggest
that for every complaint the healthcare
organization hears, it could lose up to 18
patients, a clear threat to the bottom line.
“The patient experience is a top
priority for the Cleveland Clinic; it’s our North Star,” says
James Merlino, M.D., chief experience officer. “We’ve worked
diligently to create a strategy and supporting processes to help
us fulfill the patient-first philosophy. We align our people around
the patient service culture and that shapes how we manage
patient expectations.”
Merlino says Delos Cosgrove, M.D., Cleveland Clinic’s
president and CEO, set the expectations from the outset for
providing a world-class experience based on personal encounters
he and his family had with the healthcare system. “He realized
SPECIAL HEALTHCARE ISSUE 201416 INSIGNIAM QUARTERLY
REINVENTING THE PATIENT EXPERIENCELet patient-centric care be your guide
BY TOM PECK
THE LOU RUVO CENTER FOR BRAIN HEALTH IN LAS VEGAS ONE
OF THE 22 SITES MANAGED BY THE CLEVELAND CLINIC NATIONWIDE.
02
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 17
that the entire experience is very important to the patient and
he was determined to put patients first in our organization.”
The patient experience thread is woven into every aspect of
the Cleveland Clinic’s culture. Merlino calls this managing the
360. “What patients think about us, how they get access to us,
their first impression — everything comprises their experience
with us,” he says.
Patient-centric care has turned healthcare on its head, causing
physicians, hospitals, and health systems to rethink how they
are treating their “customers”
and the long-term implications.
Jason Wolf, Ph.D., president
of The Beryl Institute, has seen
the evolution of the patient
experience. He says the patient
experience journey begins with
the integration of quality, safety,
and service.
“The patient and family don’t
delineate between these three
imperatives,” Wolf says. “They
need to be aligned around
components of healthcare
delivery. That’s why we define
the patient experience as the
sum of all interactions, shaped
by an organization’s culture that
influences patient perceptions
across the continuum of care.”
The Institute’s members have
tackled the patient experience
from a variety of angles, focusing
on specific opportunities to
improve the environment, care processes, communication,
and other aspects of the experience. One hospital in Ohio
reduced the noise level on patient units. Another addressed
parking hassles. A hospital in North Carolina implemented
bedside barcoding to make care delivery more efficient and
accurate. Another hospital in Minnesota focused on improving
physician and patient communications while a healthcare
organization in Florida created a blog from the CEO to connect
with staff, physicians, and the community. The list is endless
and demonstrates a nationwide commitment by healthcare
organizations to put patients first. Hospitals’ intentional efforts
to improve the patient experience are based on careful analysis
of their patient satisfaction data and their Hospital Consumer
Assessment of Healthcare Providers and Systems (HCAHPS)
survey scores.
Press Ganey, a leader in capturing patient satisfaction
and perception, establishes a link between profitability and
satisfaction in its 2012 white paper “Return on Investment:
Increasing Profitability by Improving Patient Satisfaction.” A
key finding cites a study of 82 hospitals where a 1 percent
standard deviation change in the quality score resulted in a
2 percent increase in operating margin. Another study of 51
hospitals found that approximately 30 percent of variance in
hospital profitability can be attributed to patient perceptions
of the quality of care. Finally,
another study estimated that
the financial implications of
moving all patients with average
Press Ganey ratings between
three and four to between four
and five was $2.3 million in
additional annual revenue.
The white paper highlights
hospital respondents’ top patient
experience priorities. The list is
comprised of mostly tactical
topics including reducing noise,
improving pain management,
enhancing the discharge process,
improving communication
among all stakeholders
(patients, staff, and physicians),
concentrating on cleanliness,
committing to hourly rounding,
and more.
Merlino and Wolf agree
that the investments healthcare
organizations make in
improving the patient experience will be repaid in the new
environment of population health management, where
coordination, communication, and collaboration are rewarded.
“Every encounter makes a difference across the continuum
of care,” explains Wolf. “All care delivery models are based
on one fundamental idea, the need to take care of patients
throughout their journey in the healthcare system. Creating
a truly great experience means concentrating on every aspect
of the experience. This includes hand-offs, communication
between staff, patients, and their families to technology, design
and functionality of space, and transitions from one care setting
to another.”
Recognizing the importance of patient and family
involvement in improvement efforts, the Cleveland Clinic
formed family councils that channel valuable feedback to the
THE INVESTMENTS HEALTHCARE ORGANIZATIONS MAKE IN IMPROVING THE PATIENT EXPERIENCE WILL BE REPAID IN THE NEW ENVIRONMENT OF POPULATION HEALTH MANAGEMENT, WHERE COORDINATION, COMMUNICATION, AND COLLABORATION ARE REWARDED.
SPECIAL HEALTHCARE ISSUE 201418 INSIGNIAM QUARTERLY
organization. The Digestive Disease Institute is a perfect
example. Leaders were puzzled over low patient scores on
cleanliness. The council pointed to the bathrooms — an
important component of the patient experience in this area
— as the culprit. Poor organization and insufficient lighting
contributed to the perception that the bathrooms were dirty.
Shelves were added and lighting was improved. The result?
Patient satisfaction scores improved significantly.
Merlino relies on a number of sources to measure success,
including HCAHPS, which reflect the voice of patient
experience. Others include councils, focus groups with
former and current patients, and other anecdotal feedback.
“The entire management group reads letters and shares
patient stories with our staff at every opportunity,” says
Merlino. “We pay close attention to anecdotal comments,
both compliments and complaints, and distribute them
throughout the organization.”
The patient experience isn’t just an American
phenomenon, as evidenced by the work that the Cleveland
Clinic and The Beryl Institute are doing with international
partners. Wolf says the Institute has strong collaborative
relationships with the United Kingdom, South Africa,
Australia, and India.
He points to the Cleveland Clinic’s co-sponsorship of
PATIENT EXPERIENCE
BY THE NUMBERS
Amount a study of 51 hospitals found of variance
in hospital profitability that can be attributed to
patient perceptions of the quality of care.
$2.3 MILLION Another study estimated that the financial
implications of moving all patients with average
Press Ganey ratings between three and four
to between four and five was $2.3 million in
additional annual revenue.
The number of people a dissatisfied
patient tells about a less-than-
satisfactory experience versus the
three a satisfied patient tells about
a positive experience.25
Models suggest that
for every complaint the
healthcare organization
hears, it could be losing
up to 18 patients, a clear
threat to the bottom line. 1830%
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 19
02 CRITICAL SUCCESS FACTOR
Reinvent patient experience: Work with patients to re-engineer core patient processes to leverage technologies and drive dramatically better patient engagement and experience. There is a major distinction between understanding the role of the patient in healthcare and actually working with the patient to redesign patient care.
a leadership conference in Turkey for ministers of health in
emerging markets and its work with the United Arab Emirates,
as well as Dr. Cosgrove’s membership on the advisory committee
for the health minister of Saudi Arabia, and a future presentation
on empathy to healthcare leaders in the Netherlands.
As the patient experience movement gains momentum,
experts like Merlino will shape the profession. Wolf says
The Beryl Institute sees the C-suite of the future including
a new member — chief experience officer. Anthony
Cirillo, president of Fast Forward, a patient experience and
marketing firm, agrees. With the growing importance of
the HCAHPS results, having a senior executive at the table
concentrating specifically on the patient experience makes
sense. The chief experience officer plays a critical role in
operationalizing the concept of the patient experience
throughout the organization by being the champion for
employees and medical staff and providing resources to
help identify and realize improvement opportunities. The
Institute is developing a certification program and has
introduced a patient experience peer-reviewed journal to
support this effort.
“At the end of the day, no one organization holds the rights
to the patient experience — we all have to share and learn from
each other,” says Merlino. “After all, it’s the right thing to do.”
SPECIAL HEALTHCARE ISSUE 201420 INSIGNIAM QUARTERLY
GETTING MORE FOR LESSIs your revenue cycle designed for the future?BY LIZ WILLDING
03
WHILE ADDRESSING REVENUE CYCLE ISSUES IN
healthcare varies from region to region around the world due
to different payer systems, one thing is for certain –– everyone
wants more for less.
“Fundamentally, the big question is, ‘How do we deliver
better healthcare outcomes with less healthcare dollars,’” says
Elizabeth H. Bradley, Ph.D., faculty director of the Yale Global
Health Institute. “The U.S. spends more than 17 percent of the
GDP on healthcare costs. This is one and a half times more
than any other country. The thing that executives struggle with
the most in any geography is how to influence the biggest
cost drivers, over which they may have very little control. In
particular, healthcare executives worry about how they can
impact wellness,” she says.
Dr. Bradley adds, “They can’t control the things that
contribute to poor health.”
Jennifer Zimmer, an Insigniam partner, says a large part of
the problem is that systems aren’t designed for the future, either
for treatment or preventive care. “Today’s systems, especially
in the U.S., are based on traditional, fee-for-service financial
models,” she says. “They are quickly becoming archaic and
need to be redesigned to serve a patient’s goals.”
Corinne Le Goff, president of Roche SAS, agrees,
especially as it relates to a growing trend toward innovations in
personalized medicine.
“Our system is set up for reimbursement of generalized
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 21
“OUR SYSTEM IS SET UP FOR REIMBURSEMENT OF GENERALIZED MEDICINE AND IS NOT DIFFERENTIATED FOR THE DISEASE STAGE.”-CORINNE LE GOFF, PRESIDENT OF ROCHE SAS
medicine and is not differentiated for the disease stage,” she
says. In oncology, for instance, she says advanced treatments may
combine different biologics based on the patient’s biomarkers.
“The system is not set up for that,” says Le Goff, who notes
that there are reimbursement pilot programs in place, but
questions whether actual information technology (IT) systems
are up to the task.
“When you talk to the government, it can be overwhelming
to say, ‘You have to totally redo your reimbursement system,’”
Le Goff says.
The ultimate answer, according to Zimmer, is redesigning
the revenue cycle. “While many models are being explored, it
essentially involves ‘establishing greater integrity or structural
soundness in the way you collect money,’” she says. “The
revenue cycle needs to be whole and intact for the realties of
healthcare in the future, and, oh, by the way, the future is rapidly
becoming now.”
Zimmer cites a recent example with U.S.-based Advanced
Homecare (AHC), a very large (Top 75) home care agency,
where their process was redesigned to make it easier for patients
to interact with the organization, so that multiple financial
touch points impact the patient just once.
“When we started in June, Advanced
Homecare had significant revenue
leakage, losing hundreds of thousands
per month on co-pays alone,” Zimmer
explains. Today the company is collecting
co-pays up front from patients, turning a
profit, and, in less than six months, is 80
percent to its fully captured goal.
“The employees, who are on the front
line with the patient, now understand
the impact their interactions about
payment have on the patient experience
and on the viability of the company.
And AHC is starting to see the money
come in. Their approach is the future
of healthcare and proof that you can
reinvent the process,” Zimmer says.
According to Joel Mills, CEO of
AHC, his organization was “stuck,”
essentially blaming a new computing
system for the organization’s financial issues.
“We were doing enough business to be successful, but not
getting the full potential from our hard work,” says Mills. “We
were stuck in not being able to bill for all the things we were
doing. We weren’t able to focus on the whole business.”
Mills adds that, “Reshaping our processes, and putting things
in the context of what’s best for the patient, turned things
around. It also helped our workforce and leaders to become
more engaged.”
Getting on top of coding issues is
another area where gains are to be made,
especially in the U.S., where healthcare
providers face sweeping changes when
new ICD-10 requirements go into
effect in October.
Mario A. Singleton, MBA/MHA,
who is the director of Hematology/
Oncology at Cone Health-Annie Penn
Cancer Center, made it his mission to
understand and address why revenue
wasn’t matching up with volume. Upon
doing a deep dive, he discovered that the
center was a couple of months behind
on billing, largely due to a coding
bottleneck.
“I didn’t think we had the proper
number of coders to keep up with the
volume and after implementing EPIC,
our new electronic medical record. After some discussions
with our oncology executive leadership team, we brought in
contract coders,” he explains. Singleton also did an audit on
recent patients and discovered that, in many cases, the system
was picking up the wrong J-codes.
SPECIAL HEALTHCARE ISSUE 201422 INSIGNIAM QUARTERLY
“RESHAPING OUR PROCESSES, AND PUTTING THINGS IN THE CONTEXT OF WHAT’S BEST FOR THE PATIENT, TURNED THINGS AROUND. IT ALSO HELPED OUR WORKFORCE AND LEADERS TO BECOME MORE ENGAGED.”- JOE MILLS, CEO OF AHC
ROCHE HAS SEEN A GROWING TREND TOWARD INNOVATIONS IN PERSONALIZED MEDICINE — AND HAS ESTABLISHED PILOT
PROGRAMS TO ADDRESS EMERGING NEEDS AND ISSUES.
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 23
BY THE NUMBERSGETTING MORE FOR LESS
COUNTRIES WITH THE HIGHEST HEALTHCARE COSTS (AS PART OF GDP)
AMOUNT CONE HEALTH-ANNIE PENN
CANCER CENTER WENT FROM LOSING
TO GAINING, PER YEAR, AFTER
ADDRESSING CODING ISSUES.
11% 9.5%SWEDEN ENGLAND
$500,00003
CRITICAL SUCCESS FACTOR
New revenue cycle: Develop a highly effective, productive, and efficient (i.e., simplified) revenue cycle.
“I asked myself if we could get the coding done in five days,”
says Singleton. “How would that impact our finances? What if
the data was input correctly the first time? ”
When the issues were addressed, the Annie Penn Cancer
Center went from losing half a million per year to gaining as
much in two years’ time.
“One thing I found was that we needed a strong team lead to
oversee the coders and to make them understand their impact
on the revenue cycle,” Singleton says. “We needed to paint the
picture and let them realize their contributions to the team. We
put a strong team lead in place and when the coders discovered
that their role was vitally important, they became much more
invested in their work.”
Meanwhile, Singleton says his organization is gearing up for
the ICD-10 shift, with preparation including training and use
of a new electronic records management system that facilitates
tracking, both for the organization and patients.
“It is always disheartening and disconcerting when a patient
brings in a big binder documenting charges that are incorrect,”
he says. “With electronic health records, they can electronically
check their bills. It adds a lot of transparency.”
Singleton says he believes that better revenue cycle
management is a differentiator and will ultimately help address
other strategic issues, including wellness.
“When you are maximizing your revenue cycle management
with accuracy, efficiency, and cost-effectiveness, your organization
can realize the possibilities of caring for the patients,” says
Singleton. “Caring for each other, and the community, while
delivering measureable results in areas of quality, service, and cost
is something we strive to do daily. Before long, you really can
begin to see the possibilities.”
17%
UNITED STATES
SPECIAL HEALTHCARE ISSUE 201424 INSIGNIAM QUARTERLY
DIVERSIFIED,YET INTEGRATED SPECIALIZATIONHow population health is putting the heart back into healing.BY ROBERT ITO
04
SHRINKING REIMBURSEMENTS AND INTENSE
cost cutting have left many physicians scratching their heads,
wondering why they got into medicine in the first place. Buried
under mountains of paperwork and feeling pulled in a million
directions, the impact of today’s changing healthcare landscape
has been a particularly harsh pill to swallow for those who are
at the heart of healing on any continent.
However, thanks to a global focus on population health,
which seeks to manage an individual’s health issues in a holistic
way, practitioners may yet have a fighting chance at returning to
their rightful place as healers. Restoring and sustaining health is
today’s mantra, versus just caring for patients when they fall ill.
One veritable force advocating for population health is America’s
Accountable Care Organization (ACO). A relatively new — and
controversial — departure from the traditional, volume-driven
fee-for-service model, the aim of ACOs is to create a system that
incentivizes practitioners to keep patients well.
Says Dr. Mike Weiss, chief medical officer at Optum Medical
Group, Southern California. “The biggest dysfunctional piece
of healthcare today is the reactive nature. Patients come to a
physician with a problem, they fix it, and move on. We need
to proactively reach out to patients of all populations, young
Incentivizing practitioners to be more proactive — as in
the case of diabetes care — is a way to shift care back to a
more holistic model.
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 25
and old.”
In this sense, he says the old saying, “An ounce of prevention
is worth a pound of cure,” has never been truer. However, he is
quick to add that executing is not without its challenges, which
he sees as two-fold. “First, physicians have to understand how
important it is to provide proactive care. Initially, it’s more work
because you have to look for ways to keep patients healthy.
Second, it is critical to engage the patient so they understand
the importance of their participation.”
Following a care protocol for diabetes is a good example.
“Diabetes doesn’t hurt and most people don’t even know they
have it until it is revealed,” Weiss says. “Our job is to intervene
before it hurts.”
Monarch took a novel approach when launching its top-
performing ACO several years ago,
initially developing the network with
its highest-performing physicians.
“Our Medicare Advantage physicians
already were coordinating care
very well,” explains Colin LeClair,
Monarch’s executive director. A
proprietary practice management
system was modeled after that used with
Medicare Advantage, putting valuable
information at the physicians’ fingertips
for fee-for-service patients.
“Previously the physicians had no
means of seeing data on these patients
unless they came in. Now they can see their MRIs, therapies,
etc. It gives the primary care physician more visibility into what’s
going on with the patients’ healthcare,” LeClair says. Just as
important, the ACO provides patients with a wide range of
services most aren’t even aware are available, like transportation
to appointments or to pick up medications.
So, in the ACO world, what exactly does preventive care
look like?
“The patient is compliant with his or her medication
regimen, fulfills required screenings, and is up-to-date on
scheduled screenings,” explains Dr. Weiss. “What we are looking
at is providing patients with all the information they need to
be successful.”
Along with happier, healthier patients, he says physician
satisfaction also improves. “Physicians want to do what’s best
for patients and the best way to do that is through access to
timely, accurate data. The data informs physicians so they can
provide better care. This, in turn, improves physician satisfaction
because their patients are doing better.”
If the population is kept healthy, the physician also benefits
financially, he explains. “In an ACO model, compensation is
based on quality. Instead of getting paid for more widgets, for
instance, we get paid for making higher-quality widgets.”
LATE TO THE GAMEAlthough a big shift for the United States, this approach is also
shared by the healthcare systems of European Organization for
Economic Co-operation and Development (OECD) countries
like the U.K., France, Germany, the Netherlands, and Sweden,
many of whom manage to do it in a much more efficient
manner — and nearly always at a much lower price.
There are currently 300 ACOs in the U.S. and counting, and
they have a lot in common with their international counterparts.
Recent healthcare legislation like Ontario’s Excellent Care for
All Act (2010) and England’s Health and
Social Care Bill (2011), share the ACO’s
focus on performance monitoring —
usually with increasingly more specific
means of monitoring improvement
in healthcare systems — and include
similar financial incentives to keep
patients from getting sick in the first
place.
There’s also been a shared focus
worldwide on how best to deal with
chronically ill patients –– that tiny 1
percent of utilizers who, according
to an oft-cited study by Rutgers
University economist Alan Monheit, account for nearly a third
of all healthcare spending in the U.S.
All of these programs seek to create more coordinated
and collaborative systems of care, with an integrated network
of doctors and specialists all working together to best serve
its population. In many ways, the U.S., with its historically
decentralized healthcare system, has a marked disadvantage to
this compared to its neighbors in Europe, with their single-payer
healthcare models. The infrastructure isn’t nearly as strong in the
U.S., let alone conducive to a collaborative mindset. How do you
get all those physicians to work together — particularly doctors
who, in the past, might not have tended to collaborate at all?
“You have to design systems by which the right thing to do is
also the easiest thing,” says Michael Ogden, M.D., chief clinical
integration officer at Cornerstone Healthcare, a medical group
with more than 90 locations in North Carolina. Cornerstone’s
recently acquired software tools allow doctors to identify their
community’s most at-risk patients.
It’s a trend that’s already well in place in New Zealand, a
country second only to Denmark in its use of electronic patient
300THE CURRENT NUMBER OF ACOS IN THE U.S.TODAY
records by primary care physicians (90 percent of the country’s
PCPs communicate online via secure networks). Additionally,
95 percent of New Zealanders are registered in the National
Health Index, an integrated system that allows hospitals and
health agencies to share information anywhere in the country.
Once high-risk patients at Cornerstone are identified,
says Ogden, they’re directed to centers like Cornerstone’s
Personalized Life Care Clinic, a specialized, coordinated care
center that focuses on the top 3 to 5 percent of the group’s
neediest patients. “They have a navigator, someone who can
coordinate care between different specialists,” he says. “We have
a dietician, a pharmacist, and access to psychology all clustered
within a life care clinic.”
WELCOME TO THE NEIGHBORHOODOne of the most recent experiments in clinically integrated
networks is the Patient Centered Medical Neighborhood
(PCMN), a healthcare model that expands on the concept of
the Patient Centered Medical Home. In 2012, Kansas-based
TransforMED received a $21 million, three-year grant from
the Centers for Medicare and Medicaid Innovation (CMMI)
to create Medical Neighborhoods in 15 communities around
the country.
By definition, the medical neighborhood concept
encompasses everything from wellness to complex care, with
coordination originating through the primary care practice and
extending to hospital systems, medical specialties, and other
community health services to support a fully integrated care
approach.
For example, TransforMED CEO Bruce Bagley, M.D.,
foresees a day when a woman can see her family physician about
a breast lump at 10 in the morning, get a mammogram at 11,
and talk with someone about the results at 1. “By the time she
goes home for dinner, she’s had a biopsy and gotten the results,
and is holding in her hand a CD-ROM of a decision aid that
can help her understand her choices and options in an unbiased
way,” he says. “That’s clinical integration.”
For ACOs, integration can apply to something as narrow
as one-on-one, doctor-to-doctor communication, or to
something as broad as previously competing healthcare
providers sharing patient records. “If you have a community
that has three hospital systems, historically those three systems
haven’t worked together very well,” says Russell W. Kohl, M.D.,
medical director at TransforMED’s Innovation for Centers of
Excellence, who is currently spearheading the group’s PCMN
project. “They’ve been focused on trying to control market
SPECIAL HEALTHCARE ISSUE 201426 INSIGNIAM QUARTERLY
Countries such as the U.K., France, Germany, the Netherlands, and Sweden have long utilized benefits of an ACO-type healthcare structure.
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 27
04CRITICAL SUCCESS FACTOR
Diversified, yet integrated specialization: Optimize physician network with strong physician leadership, collaboration, diversity of specialization, and alignment.
Amount chronically ill patients account for of all healthcare
spending in the U.S. These patients only make up 1 percent of utilizers.
1/3
$13 MILLIONAmount Pioneer ACO at Banner Health Network in Arizona netted in shared savings in its first year of existence.
30%
95%Number of New Zealand citizens registered in the National Health Index, an integrated system that allows hospitals and health agencies to share information anywhere in the country.
SPECIALIZATION BY THE NUMBERS
Percentage of current healthcare spending that is duplicative and wasteful.
share, so in areas where you have limited specialist availability, that can
certainly be an issue,” says Kohl.
A possible solution: getting these former foes to realize the cost-
cutting value of shared services. “ACOs need to look at things like, ‘Do
we really need to have five cardiac catheterization labs within one mile
of each other in the city of Boston,’” says Thomas Concannon, Ph.D.,
a policy researcher at the RAND Corporation. “They need to look at
the mechanisms they could use to coordinate service and technology.”
It’s that sort of coordination, say the proponents of ACOs, that’s key
to driving down healthcare costs. According to the Dartmouth Atlas of
Healthcare, an ongoing project under the auspices of the Dartmouth
Institute for Health Policy and Clinical Practice, up to 30 percent of
current healthcare spending is duplicative and wasteful. One of the
primary missions of the ACO is to reduce that waste, with the shared
savings being distributed between CMS and the participating ACO.
Those shared savings are the carrot, but many healthcare systems
overseas also utilize a pretty big stick. One example: Under their
diagnosis-related groups (DRG) system, hospitals in most European
countries won’t receive a second payment if a patient has to be
readmitted for the same medical issue within 30 days.
In its first year of existence, the Pioneer ACO at Banner Health
Network in Arizona netted $13.3 million in shared savings. One of its
most successful programs involves an algorithm that identifies its most
high-risk patients before they’re rolled into the ER (among the triggers
are patients who are on more than seven medications a year). In some
cases, R.N.s are dispatched right into providers’ offices and patients’
homes. But it’s the sort of integration of services that’s helping to drive
Banner’s health costs ever downward.
“There’s been a learning curve for our providers,” admits Matt Horn,
director of Banner Health’s Pioneer ACO. “Providers haven’t always
been willing to allow another care provider to come into their office
who hasn’t historically been there,” says Horn. “But the beneficiaries
appreciate it. They appreciate having that extra person there.”
SPECIAL HEALTHCARE ISSUE 201428 INSIGNIAM QUARTERLY
MINDSET OF WELL-BEINGShifting the focus is all about engagementBY LIZ WILLDING
05
TO PULL OFF POPULATION HEALTH, NO MATTER
your geography, everyone in the continuum — executives,
physicians, the clinical support staff, administrative workers, and
ultimately the patient — must be locked on one central goal:
well-being. This mindset is a quantum shift from providing care
primarily when an illness presents itself. It starts by engaging
every individual in the healthcare workforce on how their
part of the process impacts patients and ultimately extends to
fostering healthy lifestyle changes by patients themselves.
What will it take for everyone in a healthcare organization
to understand their impact on patients? It begins by showing
everyone in the healthcare delivery process how their role
impacts patients, especially by their actions or inactions, says
Jordan Safirstein, M.D., a cardiologist and member of the
Google Healthcare Advisory Board, and assistant director
of the Cardiac Catheterization Laboratories at the Gagnon
Cardiovascular Institute, Morristown Medical Center. Dr.
Safirstein gave an example of how this can impact the life —
or death — of patients requiring an emergency catheterization
procedure.
“It is important to show the emergency management
system (EMS) crews and the first responders how they can
affect door-to-balloon times if they do not meet certain time
points, and the emergency room staff is crucial to expediting
the patient once they arrive in the ER,” says Safirstein. “Then
the cath lab receiving staff is essential to rapid prepping and
troubleshooting, even before the physician steps into the room.
Safirstein continues,“Finally, there’s the role the doctor plays
in the technical achievement of timely success. All of these time
points and goals are reviewed monthly and consistent sore spots
are remedied with changes in protocols. It is an ever-improving
process, like healthcare itself, as technologies and paradigms
change. The strategy is to get people to understand their roles,
make sure they see the results on the end product, and to be
accountable by making those results visible to the rest of the
team.”
While the impact on well-being is most dramatically
illustrated in an emergency situation, it is important for everyone
in the continuum of care to understand the importance of their
job and its impact on the patient, from physicians and nurses
to the administrative staff. Healthcare executives might assume
that all the players are sensitized to the patient impact, but, says
Jennifer Zimmer, Insigniam partner, this isn’t always the case.
Making such false assumptions is a huge barrier in the
workplace, she explains. “This behavior does not create
innovative or breakthrough results. It’s business as usual.”
GOING BEYOND TREATMENT TO LIFESTYLE
While the healthcare industry traditionally defines the
“continuum” as actions taken to address a patient’s particular
disease state, addressing lifestyle issues is no less important when
it comes to preventing or slowing the progression of disease.
Again, engagement is key, especially in the workplace, directly
reaching patients with interventions that motivate healthy
behaviors.
Based on research conducted by Gallup in 2012, engaged
employees are more likely to report a healthier lifestyle than
their unhealthy counterparts, and they are less likely to be obese
or have chronic diseases. Although obesity, as a general category,
is hard to quantify, one study, published by the Harvard School
of Public Health in 2012, estimated that 21 percent of the total
U.S. spending on healthcare was devoted to obesity related
issues.
Insurance providers and the private sector are jumping into
the game, providing tools and incentives to encourage lifestyle
changes. “We’ve done a good job reaching people who are
inclined toward a healthy lifestyle,” explains Joan Kennedy,
Cigna vice president, customer health engagement. However,
she acknowledges that these people aren’t in the majority.
A universal problem, Kennedy notes, is that countries such
as China are equally befuddled about how to motivate their
society on wellness, which is facing a growing epidemic of
obesity and diabetes. China’s woes are largely due to an increase
in sedentary jobs as the country becomes more industrialized,
as well as adoption of a more westernized diet.
PRESCRIBING A DOSE OF EMPATHY
Reaching at-risk individuals revolves around empathy, says
Alexandra Drane, founder and president of Eliza Corporation,
which provides health engagement management solutions.
Teaming with the Altarum Institute, a healthcare research
organization, they surveyed more than 30,000 individuals and
found, overwhelmingly, that life obstacles often made it too
difficult for people to make health a priority.
“Life obstacles like caregiving, financial, and relationship
stress were cited as key factors throwing life out of balance,”
Drane explains, adding that unless healthcare organizations help
people address these stressors, which she calls “unmentionables,”
their wellness efforts are likely to fall on deaf ears.
This is why programs traditionally focused on disease states
have been met with low enthusiasm, she says. Simply put,
messaging that lectures people about what they aren’t doing,
hasn’t worked well for the broader population.
“People have told us that they simply don’t have time to
focus on their weight, for instance, because they are too stressed
out caring for an elderly parent. When we listened, and we
offer information on resources, nearly all of those surveyed
sought help.”
Building on the research, Eliza developed a tool called the
Vulnerability Index that helps health organizations quantify
the prevalence and impact of contextual life factors, which are
influenced by negative and positive coping responses.
Believing in the directional vision of this approach has
helped Cigna rethink its messaging, Kennedy explains. “We
asked ourselves, is there a way to re-architect our approach to
wellness, putting the pressing issues first? We found that once
you get the larger stressors calmed, you have a better chance of
addressing a person’s underlying health issues.”
Today, Cigna is in the midst of a pilot, which, based on
vulnerability, leads to different types of interventions. “We are
architecting incentives and interventions to tie to the whole
person, instead of using a fragmented approach,” Kennedy says.
Part of the solution involves tying Cigna coaches with members
and their physicians, both receiving rewards for improvement.
The approach is also driving better use of employee
assistance programs, or EAPs, which have become stigmatized
for singling out individuals seeking emotional help. “We
encourage organizations to reinvent EAPs so people feel
comfortable turning to them as a resource.”
How well is this kinder, gentler approach working?
“We are getting good participation in our pilot,” Kennedy
says; however, she is cautiously optimistic, adding that “none
of us know the answer, because we’ve never tried this before.”
THE IMPACT OF TECHNOLOGY
The use of mobile technology is also emerging as an
important enabler, with apps and fitness devices helping
individuals monitor their progress. “There are more than
40,000 health and wellness apps currently in the marketplace,
which is a bit overwhelming,” Kennedy explains. “We have a
team of experts who are evaluating and recommending some
for our online ‘Go You’ marketplace.” Go You, a Cigna portal,
allows members to access tools and services that monitor their
wellness activities.
She notes that use of apps especially makes sense in countries
where the population is highly mobile.
“In South Korea, for instance, people are entirely mobile and
you have to reach them through their phone. In other regions
of the world, you may have to work around the healthcare
architecture.”
The main point, says Kennedy, is to give support in ways that
people want to receive it — and in a way that shows you care.
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 29
05CRITICAL SUCCESS FACTOR
Mindset of well-being: Create a mindset for patient care that looks from a broad view of the overall patient’s health and well-being across a continuum of care.
SPECIAL HEALTHCARE ISSUE 201430 INSIGNIAM QUARTERLY
06
IN 2015, WOMEN’S COLLEGE HOSPITAL IN TORONTO, CANADA, WILL RELOCATE TO A STATE-OF-THE ART FACILITY (PICTURED) THAT COMPLEMENTS THEIR VISIONARY APPROACH TO HEALTHCARE.
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 31
WHAT HAPPENS WHEN YOU MAKE A 180 DEGREE
shift in your business model, moving from acute care to
an ambulatory care model? Women’s College Hospital
in Toronto, Ontario, Canada, did just that, challenging
traditional thinking at all levels of its organization about
healthcare delivery. An inpatient acute-care hospital with
130 years of service, this radical shift was precipitated by a
pre-arranged merger with two other healthcare institutions
in 1998. Eight years later, administrators successfully
negotiated with the government of Ontario to once again
be a stand-alone organization.
“Part of the price that we paid for independence was a
stipulation from the government of Ontario that we could
operate only as an ambulatory facility,” says Marilyn Emery,
president and chief executive officer of Women’s College
Hospital. “We could have chosen to go down the mainstream
route, but we chose instead to take a visionary approach, one
more suited to where we felt healthcare is headed. While we
continue to focus on advancing healthcare for women, we
are aggressively addressing the transitions between acute-
care and post-acute care.”
Why has Women’s College Hospital thrived in its pursuit
of outpatient excellence? How has it succeeded when
others are struggling? What does the future look like for
the organization?
Emery credits a comprehensive 2½ year strategic planning
process guided by the hospital’s mission as the foundation
upon which all programming has been built. The process
was driven by the need to answer two questions — who
is Women’s College Hospital and what did it provide
to the community? The honest conversations that took
place among key stakeholders, including board members,
physicians, staff, and the community, provided a bridge
between women’s healthcare and ambulatory care. A key
driver was the provincial government’s interest in shifting
people from inpatient care, the most expensive type of care,
to outpatient care through innovation that could ultimately
result in people never being hospitalized in the first place.
The strategic roadmap that emerged defined a clear vision
and focused on identifying gaps and developing innovative
services, not duplicating existing services.
To achieve its mission, the organization identified three
NEW HORIZONS A model for the future of healthcare: Women’s College Hospital
BY TOM PECK
THE HOSPITAL DEFINES ITS VISION AS BEING, “CANADA’S LEADING ACADEMIC, AMBULATORY HOSPITAL AND A WORLD LEADER IN WOMEN’S HEALTH.”
SPECIAL HEALTHCARE ISSUE 201432 INSIGNIAM QUARTERLY
specific areas of focus: health for women, health system
solutions, and complex chronic conditions. These are
supported by six innovation streams: driving systematic
solutions in healthcare for women,
preventing acute care admission
and readmission, enabling superior
coordinated care, transforming
inpatient care models to outpatient
care, enabling system integration
and care transitions, and building
a virtual hospital. Three corporate
directives guide the hospital’s
decision-making and action
planning: drive the innovation
agenda, strengthen the capacity to
lead from its mandate, and grow its
academic impact.
Emery says the senior team talks
about the corporate directives
daily. “It really is the culture of
the organization. The directives
enable close integration between
research, clinical care and everything else that goes on in
the organization,” she says.
Women’s College Hospital has been deliberate about
designing outpatient programs to serve marginalized and
underserved patients — a gap identified in its strategic
plan. An example is the Toronto Birthing Center, a
midwife run program located in
a free-standing facility in a high-
needs neighborhood. The center
is designed to improve access for a
variety of frequently underserved
groups, including Abor iginal
women, immigrant women, inner
city women, women who identify
as LGBTQ, refugees, teens, and the
noninsured.
The hospital operates in an
undefined space in healthcare, so it
is difficult for people to grasp what
it does. It is used as an incubator for
the rest of Canada’s health system.
The work it is doing has grabbed
the attention of health leaders across
Canada and around the world.
“We are often contacted by other
organizations interested in learning who we are, what we
do, and how we do it,” says Emery. “We just hosted a group
from Vietnam and our physicians and scientists are frequent
“WE CAN’T FALL BACK ON INPATIENT BEDS, SO THAT’S CREATED A TREMENDOUS OPPORTUNITY FOR INNOVATION.” - MARILYN EMERY, CEO AND PRESIDENT, WOMEN’S COLLEGE HOSPITAL
speakers on the international scene. We’ve adapted concepts
such as the virtual ward from the United Kingdom. A
U.K. delegation visited our organization, studied the
improvements we had made, and took our ideas back with
them.”
Partnering with other healthcare providers and
government agencies has been vital to Women’s College
Hospital’s success. “We need the ability to refer patients
to inpatient facilities,” says Emery. “When you’re looking
to solve problems that are difficult for everyone, you need
multiple perspectives and resources. We constantly ask other
providers what we can do to help them meet the challenges
and resolve the problems they are facing.”
Heather McPherson, Women’s College Hospital’s
executive vice president of patient care and ambulatory
innovation, says data related to patients’ expectation of
ambulatory care has helped align physicians and staff with
the hospital’s mission and strategic plan. Patients expect
to wait around 20 minutes for service in an outpatient
care setting. Benchmarking the organization’s actual
performance against these expectations, as well as against
the performance of peer organizations and incorporating
patient feedback on their experience, has provided evidence
to help the hospital improve.
“We can’t fall back on inpatient beds, so that’s created a
tremendous opportunity for innovation,” explains Emery.
“We have one of the biggest breast reconstruction surgical
programs in Ontario. The average length of stay for this
procedure is five to six days. Our interdisciplinary teams
spent one year developing a care pathway that created higher
quality care, increased patient satisfaction, and reduced the
amount of time at the hospital to 18 hours.”
By adopting systematic innovations across their business
model, Women’s College Hospital is a living embodiment
of what’s on the horizon for the healthcare industry.
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 33
06CRITICAL SUCCESS FACTOR
New horizons: Expand patient care beyond physician-centered and acute-hospital-located care delivery.
BY FOCUSING ON INCREASED PATIENT SATISFACTION, WOMEN’S COLLEGE HOSPITAL DEVELOPED A PATHWAY TO INTERDISCIPLINARY IMPROVEMENT.
SPECIAL HEALTHCARE ISSUE 201434 INSIGNIAM QUARTERLY
HEALTHCARE LEADERS, OUR TIME IS NOW“Innovation” is today’s critical objective.BY LIZ WILLDING
07
WITH SO MANY DRAMATIC SHIFTS HAPPENING
across the healthcare landscape, now is the time for innovation.
Business as usual will no longer suffice, whether it’s coping
with an aging population fraught with noncommunicable
diseases or shifting to a focus on wellness.
“This is our moment in time to transform healthcare,” says
Nathan Owen Rosenberg, Insigniam founding partner. “It is
time for healthcare leaders to define and realize a new, bold
future for the care and health of our population.”
Globally, a host of forward-thinking organizations already
have read the tea leaves, actively innovating demonstrations
into what global healthcare will look like in the future. At the
Mayo Clinic, for instance, approximately 65 people are actively
dedicated to identifying and testing new ideas, using human-
centered design methods.
“Our approach is to transform the way people experience
healthcare,” explains Douglas L. Wood, M.D., who is the director
of the Center for Innovation at Mayo Clinic. Emphasizing
that “we are fundamentally interested in putting the needs of
people first,” he references research that identifies key reasons
why people often don’t seek care due to barriers created by
providers and the system.
“We listen to people’s needs, and we often try to force them
into care, blaming them if they are noncompliant. People also
spend most of their time out of clinics; we need to develop
and deliver care where they are, instead
of forcing them to go to clinics where
they may not feel comfortable.”
Dr. Wood adds that “we have lots
of roles for sickness care, but not a lot
for health. Our systems force protocols
on people that are rigid and not very
helpful.”
Types of innovation projects coming
out of Mayo Clinic’s Center for
Innovation range from changing the
delivery of care for expectant mothers
–– even equipping them with Doppler
ultrasound machines so they can
listen to their babies — to creating a
laboratory in an assisted-living facility to
manage transitions from hospital to home settings, and even
embedding “designers” who are studying ways to mitigate the
stresses of campus life into the campus environment at Arizona
State University.
Similarly, integrated care consortium, Kaiser Permanente,
operates its “Hospital of the Future”
project, creating scale models of an
integrated system linking doctors
and clinics, as well as a health
insurance component, all housed
inside its 37,000-square-foot Garfield
Innovation Center in San Leandro,
California.
Cross the ocean to China and there’s
the “Innovation City” on the outskirts
of Wuhan, the country’s newest symbol
of the government’s mandate for
innovation. Complete with two dozen
structures, it was no more than rolling
farmland just two years ago.
The European Union has also
embraced the concept of innovation, establishing the
“Innovation Union – A European 2020 Initiative.” One of
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 35
“IT IS TIME FOR HEALTHCARE LEADERS TO DEFINE AND REALIZE A NEW, BOLD FUTURE FOR THE CARE AND HEALTH OF OUR POPULATION.” - NATHAN OWEN ROSENBERG, INSIGNIAM CO-FOUNDING PARTNER
SPECIAL HEALTHCARE ISSUE 201436 INSIGNIAM QUARTERLY
LEADERSHIP MANDATE
PROPRIETARYPROCESSES
INSIGNIAM’S FOUR PILLARS FOR INNOVATION
its goals is to create a single European research area to attract
science and technology talent and funding as a means to
compete with U.S. and Asian markets.
In Switzerland, heavy emphasis also is being placed on
innovating business processes, with a new hospital financing
system, launched in 2012, addressing access to capital and
encouraging competition and consolidation. This program is
focused not only on efficiency, but also on care and quality.
CREATE VALUEAt the end of the day, “Innovation is about delivering new
value,” says Nathan Owen Rosenberg, Insigniam co-founder,
noting that there are “huge challenges in the delivery of
services.”
Indeed, says Rosenberg, who believes the only way to survive
in today’s volatile environment is to innovate with a focus on
accountability. The simple truth, he says, is that patients, as they
become more accountable for their care, “are going to be
shopping,” which creates a new layer of competition.
Robert E. Johnston, Insigniam consultant and co-author
with J. Douglas Bate of The Power of Strategy Innovation, agrees.
Since publishing in 2003, he says he has observed global
healthcare innovation mature to a place outside of research and
development.
“We are now moving from ad hoc to breakthrough,
quantum innovation,” he explains. “That is the new high bar.”
To innovate effectively requires a very deliberate and
organized effort, he explains, with Insigniam’s approach based
on four pillars for innovation:
1. Leadership mandate
2. Dedicated infrastructure
3. Proprietary processes
4. Supportive culture
“First, the C-Suite must send a very loud and clear mandate
for innovation across the enterprise that is relevant to all
employees,” Johnston says. “They also must give the necessary
permission to do fresh thinking, and they must back this up
with funding, people, time, and space.”
Johnston says that the creation of innovation labs on the scale
of Mayo and Kaiser Permamente is becoming an increasingly
common phenomenon; however, it is possible to scale up in a
less grandiose way.
“One way to jump-start embedded innovation in the DNA
of an organization is to commit to a yearlong innovation
immersion,” he explains. “Once you have a vision for your
future organization, you plan backwards. This way you
eliminate all the noise that over time becomes irrelevant.”
The metaphor he says he uses the most these days is that
“every organization is on its own innovation journey. You have
to get from point A to point B.”
Working with an organization in
South Africa, Johnston describes an
innovation immersion experience
that began with two executive teams.
In short order, they chartered 26
additional innovation, or I-Teams, to
address both tactical and strategic issues.
After the initial launch, a mid-year
“jam session” was held, and the energy
and enthusiasm level was “palatable,”
he says. By the end of the year, which
wrapped up with a celebration, many
of the teams had completed their work,
resulting in pipelines of new business
opportunities and significant cost-
saving opportunities.
For this company, what began as a
one-year effort is now in the third year
of its journey.
While attending a recent conference hosted by the
Massachusetts Institute of Technology (MIT), Johnston
recalls watching “Hack-a-Thons,” which involve participants
“hacking their way through how clinical trials are conducted
today.”
“It’s difficult to enroll patients and even tougher to keep
them in the program,” says Johnston. “The idea was to attract
and keep patients in for the long haul by offering them, up
front, free drug therapy, pending approval by the Food and
Drug Administration (FDA).”
MIT has staged 10 of its “Hack-a-Thons” around the world
in hospital organizations, and out of these have come 10 new
ventures that are receiving third-party funding.
BEWARE THE BARRIERSHowever, while innovation can breathe new life into an
organization, there are barriers that can derail even the best
efforts.
Rosenberg says executives should also be aware of their
“corporate immune system,” which repels ideas because
“that wouldn’t happen here” and “senior management will
never go for that.” Equally debilitating is corporate myopia,
where organizations “have a very narrow lens for how they
define business,” and corporate gravity, which holds down
organizations that operate under a “can’t-do mindset.”
Ultimately, innovation is only as good as its execution.
Insigniam conducted an Executive Sentiment survey in 2013,
asking 200 executives how prepared they are to innovate
and execute on their innovation ideas. An overwhelming
87 percent said innovation is the
most important or a very important
factor in their organizations’ ability
to succeed and strengthen their
competitive advantage in the next
12 to 13 months. However, only 15
percent felt their organizations were
well prepared to generate the needed
level of innovation.
“Many of today’s health leaders
are in shock by all the changes facing
healthcare,” Johnston says. “They
are catatonic. I’ve heard leaders say,
‘When we look into the future, we
don’t know what is going to happen.
It is like we’re walking into a dark
room.’
“Well, at some point, the lights are
going to come on. The organizations that are most prepared
to handle the opportunities will win … and the others will be
left behind.”
He adds that while it is entirely impossible to predict what
the future will hold, “you don’t want to be surprised by it
either. You can’t predict, but you can influence,” which is what
innovation, at its core, is all about.
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 37
07CRITICAL SUCCESS FACTOR
Embedded innovation: Embed in the organization a competency for creativity to continually innovate and rapidly execute innovation and change.
“WE NEED TO DEVELOP AND DELIVER CARE WHERE THEY ARE, INSTEAD OF FORCING THEM TO GO TO CLINICS WHERE THEY MAY NOT FEEL COMFORTABLE.” - DR. DOUGLAS L. WOOD, DIRECTOR OF THE CENTER FOR INNOVATION, MAYO CLINIC
IT IS AN INDISPUTABLE FACT THAT INFORMATION
technology is revolutionizing healthcare. An explosion
of mobile applications (mHealth) is enabling patients to
use their smartphones to monitor their chronic conditions
and connect with their physicians. Blood pressure, cardiac
monitoring, and blood glucose monitoring are early entrants
in the world of mHealth. As an enabler, IT is helping to
care for patients in their home versus the hospital, providing
real-time information that physicians can monitor and react
to immediately.
The implications are fantastic and seemingly once relegated
to the world of science fiction. For instance, Proteus, a digital
health company, recently received FDA approval to manufacture
pills with edible electronic sensors. An online
mHealth app receives data transmitted by the
sensors, enabling physicians to track a patient’s
medication compliance. This technology
addresses the costly problem of medication
noncompliance, estimated to cost the U.S.
healthcare system alone as much as $290
billion.
A report published by research2guidance predicts that by
2017, the mHealth market will reach billions of people around
the globe via their smartphones and tablets. Research and
Markets, an international market research firm, estimates
the current value of the global mHealth apps market at $6.6
billion, growing to $20.7 billion by 2018. The mHealth apps
market in the United States was estimated to be valued at $2.9
billion in 2013.
The report predicts the highest growth will occur in diabetes
management devices due to the increasing global burden of the
disease. The proliferation of apps related to diabetes validates the
prediction. OnTrack for Android smartphones allows diabetics
to track blood glucose highs and lows, food intake, medications,
SPECIAL HEALTHCARE ISSUE 201438 INSIGNIAM QUARTERLY
LEVERAGING NEW TECHNOLOGYTake technology to a personal levelBY TOM PECK
08
blood pressure, pulse, exercise, and weight all in one place.
SiDiary captures, stores, and analyzes relevant data for use in
diabetic therapy. The Diabetes Diet app contains hundreds of
healthy recipes. A recent clinical trial conducted by WellDoc
demonstrated that combining patient behavioral coaching via
mobile applications with blood glucose data, lifestyle behaviors,
and patient self-management data substantially reduces glycated
hemoglobin levels over one year.
The Food and Drug Administration projects that the mobile
app market will grow by 25 percent annually for the near future,
with companies investing record amounts in developing new
health apps. Consumers will find more and more options from
which to choose. There are more than 40,000 health apps
currently on iTunes, including calorie counters, prescription
reminders, and physician and hospital locators.
As of September 2013, the FDA had cleared nearly 100
mobile medical apps including blood pressure monitors, apps
that send real-time readings of electrocardiographs to physicians,
and apps that access vital signs for use in emergency cardiac care.
“Mobile apps are unleashing amazing creativity, and we
intend to encourage these exciting innovations,” says Bakul
Patel, M.S., MBA, senior policy advisor to the director of FDA’s
Center for Devices and Radiological Health. “At the same time,
we have set risk-based priorities and are focusing the FDA’s
oversight on mobile apps that are devices for which safety and
effectiveness are critical.”
Physicians also are embracing mobile technology via their
tablets to access a variety of data including EMR information
and drug reference facts. A 2012 survey by InformationWeek
asked IT teams which mobile computing devices physicians in
their organization were using for medical purposes, and more
than two-thirds, 66 percent, reported iPads or other tablets — a
21 percent increase in just 12 months.
The expansion of mHealth also promises to address a looming
physician shortage by enabling physicians to monitor large
numbers of patients remotely, respond to their questions quickly,
and make better, more informed decisions about their care.
In a recent TED Talk, Eric Dishman, director of proactive
health research at Intel Corporation, said the current healthcare
system “must change,” and it’s up to individuals to wake up
and take control of their health. Dishman’s vision is one where
patients will no longer be tethered to a central location for care.
They will be able to take an active role in their own well-being.
Information technology will facilitate care coordination among
a team of caregivers, eliminating the all-too-common practice
of disparate specialists prescribing duplicative or contraindicated
drugs to patients, often resulting in costly hospital admissions.
“Information technology has moved from a position of
dread to a position of desire,”
says David Muntz, former
principal deputy director of
the Office of the National
Coordinator on Health
Information Technology.
“Healthcare really wants
technology now, and I see
that as a real sea change,” he
says. “The government has
been using a stimulus program
effectively in combination
with policy to encourage
healthcare organizations
to adopt technologies that
are interoperable. This will
revolutionize healthcare
because it will enable people
to go where they want to go, without duplication, and they
will be able to access all points along the continuum of care.”
Dishman also advocates using information technology to
accelerate care customization. The ability to map individuals’
entire genetic makeup will allow healthcare providers to
build specific predictive models that will eliminate the costly
guesswork that often plagues today’s system and replace it with
targeted therapies that will improve effectiveness and reduce
costs.
Muntz seems to concur, adding “Information technology is
unlike any other resource available in healthcare. It allows you to
hardwire processes that you can’t control and assure outcomes,”
he says. “Health information technology helps create better
avenues and opportunities for communication, coordination,
and collaboration.
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 39
08CRITICAL SUCCESS FACTOR
Leveraging new technology: Establish a strong capability and capacity to leverage information technology, including but not limited to mobile and web technology.
BILLION
$2.9THE MHEALTH APPS MARKET ESTIMATED
VALUE IN 2013.
AS THE HEALTHCARE INDUSTRY EMBARKS ON
reinventing itself, going about the hard work of transforming
managers into leaders truly is a critical success factor. However,
does an industry that is currently stymied by outdated
hierarchical management structures, functional silos, and
cultures based on rewarding activity versus outcomes have the
institutional fortitude to step up and invest in “making” leaders
who can redefine the future? If so, where will the next wave of
leaders come from? As the industry moves toward population
health, how will physician leaders factor into the equation?
Executives at Cone Health, a successful, six-hospital
healthcare system in North Carolina with approximately 10,000
employees, have asked all
of these questions and
more. In a process that
began by envisioning
the future, they set out
several years ago to
define new goals and
values. At the behest of
R. Timothy Rice, Cone
Health’s CEO, they set
the “audacious goal” to rank in the top decile nationally on
all major quality measures by 2015, realizing, of course, that a
“business as usual” management style no longer would suffice.
“We needed a highly motivated and empowered team that
consistently put patients and their needs first,” explains Joan
Evans, Cone Health’s vice president, organizational effectiveness
and performance. “Our managers had to make the shift to
being leaders for the future. They had to learn how to ask hard
questions, including, ‘What’s the value? How do we measure
it? Who is going to be accountable?’ We had to teach them
how to do that.”
With the shift to population health, it also became clear that
40 INSIGNIAM QUARTERLY
TRANSFORMATIONAL LEADERSHIPFor Cone Health, “unleashing the tiger” of transformation begins with empowerment.BY NATHAN OWEN ROSENBERG
09
SPECIAL HEALTHCARE ISSUE 2014
more physician leaders would be needed. Since many lacked
the necessary collaboration skills for group decision-making, a
dedicated training program was required.
SHIFTING FROM MANAGERS TO LEADERSCone’s first step began with an increased focus on
communication skills. “Because
system thinking is critical, moving
from hospital to population
health, our leaders now had to
think upstream and downstream,”
Evans explains. “What’s happened
before to the patient? What’s
happening after we care for
them? To be mindful of the voice
of the customer, they needed to
learn how to be fully present
with patients and employees,
developing deep listening skills.”
From there, the focus expanded
to culture, working with leaders
to help them inspire and motivate the employee base. “We
needed a leadership team who could talk about
what mattered most in a new way and who were
able to generate action to inform our new future,”
Evans says. “To do this, we had to learn how
to unhook from the past, invent the future, and
engage employees.”
Although it may sound simplistic, Evans says
a key realization for leaders and employees alike
was that “the transformation starts with you. It’s
a rude awakening for some, but as leaders, that’s
what we have to focus on.”
“We also emphasize the importance of
language in what we say and how we say it,” says
Evans. “You can use the power of language to
create a different response in people and to align
them around a possibility bigger than themselves.”
ENLISTING PHYSICIANSIn addition, Cone created a dedicated
physician leadership academy, identifying and
training “rising stars with leadership potential,”
says Amy Martinez, director of organizational
development. “Because of the changes coming
about with population health, physicians have
to be able to collaborate in ways as never before,
which is new for them. In the case of primary
physicians, they are becoming the hub with everyone else being
the spokes turning around them. It’s a big paradigm shift.”
Consisting of a yearlong commitment, the curriculum
includes a personal assessment, measuring everything from
leadership competencies and personality attributes, to an
individual’s appetite for approaching and accepting change.
Executive coaching is also
built in at all stages, including
feedback on action learning
projects, which are designed
to address critical systemic
challenges while serving as
a leadership development
opportunity.
One cohort consisting of 18
physicians has completed the
academy, while another group
of 20 is just beginning. Several
of the physicians who have
completed the program are now
integrally involved in the system’s
strategy effort; another is leading Cone’s ACO; and yet another
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 41
“THE TRANSFORMATION STARTS WITH YOU. IT’S A RUDE AWAKENING, BUT AS LEADERS, THAT’S WHAT YOU HAVE TO FOCUS ON.” - JOAN EVANS, VICE PRESIDENT, CONE HEALTH
SPECIAL HEALTHCARE ISSUE 201442 INSIGNIAM QUARTERLY
“For the first time in its history, to get everyone on the same page, Cone elevated its effort to include all employees, staging all-hands meetings at every level. This ‘unleashed a tiger’,” says R. Timothy Rice, CEO, and is paying off in measurable, sustainable results that include:
UNLEASHING A TIGER
09CRITICAL SUCCESS FACTOR
Transformational leadership: Leaders must be able to envision and execute on new, unprecedented futures while being highly skilled in the interpersonal skills needed to partner with physicians and care providers and to support and encourage creativity while maintaining discipline.
is immersed in a primary care collaborative effort on
Medical Homes. “This effort was put together to address
the new healthcare era, recognizing that physician
leadership is integral to success,” Martinez says. However,
she notes that juggling meetings while continuing to
see patients “can be very difficult for physicians from
a life balance standpoint.” An underlying goal was to
train more physicians “so the same people aren’t always
carrying all of the load.”
CREATING A COMPETENCY MODELBecause “leadership development is not a one-
time thing,” says Evans, Cone also recently redesigned
its leadership competency model as the basis for its
management development. In 2013, this was integrated
into every manager’s performance assessment, followed
by a development plan and access to tools and resources.
Developed by a group of leaders in a co-creative
process, the model identifies 10 key competencies,
starting with being accountable and including being a
visionary strategic leader, a relationship builder, a leader
of people, having a patient-centered service orientation,
being a talent developer, and a breakthrough thinker. In
addition, exceptional leaders must be effective resource
managers who understand the importance of sound
financial planning, as well as have a keen community
focus and are continuous learners.
GAINING ACCEPTANCEWhile most of the management team at Cone has
enthusiastically accepted the changes the organization
has put in place, the transformation has not come without
some resistance. “By and large,” says Evans, “the people
who can’t make the shift are the exception rather than
the rule. When dealing with resistance, she says there
are two key aspects to consider: 1) Does the employee
have the ability; and 2) Is the employee willing? “No
amount of coaching will help if there is an unwillingness
to change.”
“You may have some people who have been very
successful in the old, command-control model that just
will struggle to make the leap to inspirational.”
For those who do come along for the ride, however,
she says the experience can be nothing short of life-
changing. “Shared commitment and shared vision can
lead to personal transformation,” which brings its own
rewards.
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SPECIAL HEALTHCARE ISSUE 201444 INSIGNIAM QUARTERLY
Accountability is more than just lip service. It’s strategy. BY CHRIS WARREN
FAR TOO MANY ORGANIZATIONS BELIEVE
that creating a corporate culture of responsibility and
accountability simply requires coming up with a statement of
values, putting it on some posters and hanging them around
the office. If only it were that easy. Nathan Rosenberg, a
founding partner at Insigniam, says that culture is much
more powerful and pervasive than a bunch of aspirational
bullet points. “It’s whatever is reinforced and it acts like an
invisible force field,” he says. “Resources and strategy are
important, of course, but a significant part of what people
can and cannot accomplish at an organization is a product
of corporate culture.”
In other words, as much as words matter — and they do
— communication about values only makes an impact when
HOW WELL ARE YOU FULFILLING YOUR PROMISE?
10
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 45
it truly reflects how people in an organization act. And that
means that changing culture to become more accountable
and responsible demands a lot of work, especially in healthcare.
Why? Rosenberg believes that the quirky and complicated
business model in which patients don’t pay directly for the
services they receive means providers are often insulated from
the kinds of signals that motivate companies to create cultures
geared around responsibility and accountability to patients.
“It’s not customer satisfaction that drives success. It’s payer
satisfaction,” he says. “No matter how great a job you do, the
federal government or an insurer is only going to pay you X
amount for a particular procedure.”
Accountability has become one of those catchphrases that
is used over and over again without common understanding
of what it means, says Rosenberg. “To give an account is
to give a reckoning — a reckoning of results but more
importantly a reckoning of the actions, and inactions, that
contributed to the result.”
In true accountability, there is a focus on actions. Yes, there
are always circumstances one has to contend with that we
cannot control. Our actions and inactions are how we have
power, the ability to respond. Building cultures in which
NATHAN ROSENBERG
SPECIAL HEALTHCARE ISSUE 201446 INSIGNIAM QUARTERLY
patients, physicians, nurses, and administrators each own the
ultimate outcome, and their actions and inactions to bring
about that outcome, takes a constant
reinforcement of that mindset.
THINK SMALL
For large organizations especially,
the prospect of reorienting a
culture to be more accountable and
responsible can be daunting. Is there
a secret one-size-fits-all approach to
implement systemic cultural change?
No, in fact, there isn’t. At least that
was the experience Richard Buchler
had when he worked with the
Sutter Gould Medical Foundation
(SGMF) in Modesto, California. A part of the Northern
California medical group Sutter Health, SGMF utilized so-
called rapid improvement events aimed at addressing hyper-
specific deficiencies in how the organization functioned to
establish real accountability. With Buchler as a facilitator,
these improvement events brought together a task force of
between nine and 12 people that
always included an administrator,
a physician, frontline workers,
subject-matter expects, and a
patient.
In one instance, Buchler worked
on patient registration, looking for
ways to make it faster, cheaper,
and more satisfying for patients.
Besides coming up with ideas for
improvements, a central task was
instituting accountability. “Each
weeklong event always included a
plan afterward to make sure that any
improvements that were made were tracked and improved
upon long after the event,” he says. “A central part of any
improvement project was setting up accountability. New
processes established were written up as standard work that
UNLESS EVERYONE HAS A ROLE — AND RESPONSIBILITY — TO AFFECT ACCOUNTABILITY,
YOU’RE HEADED FOR A BREAKDOWN.
TAKING THE TIME TO DELINEATE WHO MUST ANSWER FOR SPECIFIC RESULTS BEING ACHIEVED OR NOT IS ABSOLUTELY ESSENTIAL.
all staff were expected to follow at all times.” Managers, too,
were tasked with making sure any new procedures were
followed, and director-level executives were also expected
to do routine “rounding” tours to verify that changes were
being embraced.
DEFINE EVERYONE’S ROLE
Jon Kleinman has a pretty simple way to illustrate the
importance of clearly defined roles when it comes to creating
a culture of accountability. Kleinman, a partner at Insigniam
who specializes in leadership development and innovation,
says it’s best to picture an organization as the pit crew for a
Formula One racer. “That car rolls in for a stop, and you’ve
got just a few seconds to change all four tires, fill the gas,
and do a bunch of other things. You can imagine what
would happen if you had unclear lines of accountability,”
says Kleinman. While often difficult, Kleinman believes that
taking the time to delineate who must answer for specific
results being achieved or not is absolutely essential.
Leaders at Buffalo, New York-based Catholic Medical
Partners have devoted a lot of time and effort to defining
the myriad roles of numerous stakeholders in its network
of 900 independent physicians. “What we have created is a
culture around collaboration,” says Dennis Horrigan, CEO
of Catholic Medical Partners. “They’re a diverse group of
doctors and they’ve told us they want help to deliver better
quality. We helped them by supporting the adoption of
electronic health records so they and their staff could make
better use of technology for care management. We also had
success in advocating with the health plans on their behalf.”
Naturally, this is only part of the equation. Physicians
who are part of the Catholic Medical Partners network
must meet clearly defined standards for delivering
evidence-based medicine, reducing readmission and
infection rates, and other measures. Horrigan says
that Catholic Medical Partners, which has garnered
numerous awards for its use of technology and
quality of care, has also made a significant effort to
encourage patients to play an active role in their
treatment. In part, that involves providing patients
with web-based educational materials so that they
can better understand their illnesses. But it’s also
about ensuring that patients who need it have access
to care coordinators, typically registered nurses, who
can make sure they have the right medications,
arrange follow-up appointments, and visit them in
their homes to see that all their needs are adequately
addressed. Not only does this approach boost patient
involvement and accountability, it also reduces expensive
hospital readmissions.
MEASURE AND RESPOND
An essential step toward creating a culture of accountability
is some sort of objective measure of whether goals are being
met. In the case of Catholic Medical Partners, Horrigan
says that doctors are supplied with a vast array of data
about their performance, along with resources to improve
whenever necessary. “How well do you treat hypertension
and diabetes? They know because we can help measure it,”
he says. “We are identifying areas of improvement and giving
them patient satisfaction data.”
The aim is for doctors to always improve and stay a part
of the healthcare network, says Horrigan. But accountability
also means taking some action when physicians don’t meet
their commitments. “In some cases, we have asked doctors
not to continue in our organization because we don’t think
they are fulfilling their promise,” he says.
LEADERSHIP MATTERS
While it’s true that a few nice words from a CEO are
not enough to establish a culture of accountability and
responsibility, it’s also true that executive team support is
critical. Buchler says little would have been accomplished
during his time at Sutter Health without the backing of key
leaders. “The most important key to setting up accountability
in healthcare is that the effort to do so is led by the CEO,”
he says. “Without his or her buy-in, physicians can easily get
away with doing runarounds of the new processes if they
perceive them as being inconvenient.”
SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 47
10CRITICAL SUCCESS FACTOR
Culture of responsibility and accountability: In order to drive demonstrated value, both patients and providers will need to operate at higher levels of accountability. Organizational and clinical culture, processes, and structures must be organized to institutionalize accountability and responsibility.
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