#1 Priority for Your Front Office Team

A surgeon can be the best surgeon in the area or the world, for that matter. But, if his/her front office isn’t doing its job right, this expertise means nothing. It’s the equivalent of having the best quarterback on the field, but the front line can’t block, the running back can’t run and the receivers can’t catch. A team simply can’t win, with only one effective player. So how effective is your team?

As in football, a front office must know the drills and apply them daily. First, they need good people skills. It’s a MUST that they always put the patient first. As the saying goes, “if Mama ain’t happy, ain’t nobody happy!” How does this apply to your patients? Think about it, if your staff mishandles an issue in the front office, they’ve not only upset the patient, but the patient’s family/friends and everyone sitting in your front office, i.e. other patients and potential customers. If you can do one thing for your staff, teach them how to handle difficult situations. First, train them to live and breathe the two rule standard as an initial reaction to a disgruntled patient: “Rule #1 – The patient is always right, Rule #2 – If the patient is wrong, refer to Rule #1.” By making the patient feel that they are right, the anger and emotions surrounding the situation are diffused immediately. Second, in resolving a patient issue, take them to a private area and work through the patient’s issue in a positive manner. If a staff member has done something wrong, require that the staff resolving this issue with the patient do 4 things: (1) admit wrong doing, (2) openly acknowledge what was done incorrectly, (3) apologize for the mistake, and (4) come up with an action plan that you will implement immediately to ensure this doesn’t happen again. If your staff does this, it’s a guarantee that your patients will come back, as well as become life-long customers and most importantly, tell their family and friends of the great experience they had at your office and/or surgery center and what a top notch ophthalmologist you are.

The second most important duty of front office staff is how they treat each other. The Golden Rule is always a good place to start. This rule is “treat others, as you would like them to treat you.” If you instill this in each and every one of your people and let them know that you expect them to live this daily, your personnel issues will be minimal. In the last year, one of cataract outsourcing team members violate this rule. Rather than treat it as an isolated incident and address with only this particular staff, the supervisor gathered the entire group together the day after the episode and presented them with a one page statement. He read it out loud and had discussions with them what this meant on an individual level, as well as a team. He went over points about how our society, as a whole, has become less professional and respectful of each another. They discussed this and it was agreed that the team needs to work harder in making sure these types of behaviors/attitudes don’t permeated their work environment. They discussed how they could have handled the situation differently. In the end, the supervisor, along with each staff member, signed this document acknowledging their pledge to treat each other professionally and with the utmost respect, at all times.

Another aspect of front office service applies to your facility staff. If you haven’t already done so, you need to encourage, promote, and require your facility staff to treat your office staff with the upmost respect and view them as a key customer. In addition, they need to do the same for all surgeon users’ office staff. Your people must view these groups of people as key customers, i.e. same top notch customer service, as the staff gives the patients. Granted not all physician offices have the greatest customer service-oriented people working their front desks. But, encourage your staff to look beyond this and to keep reminding themselves that a surgeon’s staff is the gatekeeper of the facility’s patients. Again, if these key people are happy, I’ll guarantee you the facility case load will increase.

Finally, your staff needs to be dutiful in completing the tasks of scheduling, pre-certing, registering, preparing patient for surgical protocol and expectations, billing and collecting payments. However you might remind them that if poor customer service exists and/or prevails, there will be no need to pre-cert, register, etc…, as customers will be non-existent. Therefore, the #1 priority must always be customer service to both external and internal customers.

Teamwork with pride

The OR can be “brought to life” by all of the people that spend their daily work hours involved with it.  The attitude of the OR “life” is made by each person that comes in contact with the room.  This can make it a beast or a gentle giant.

The best practices for running an OR start with teamwork and pride.  Each person involved should be able to work with the others in the room and know the daily routine. Each person has to take pride in the work that they do.  The circulator must be ready to be in charge and know where all items are.  The room has to be kept stocked – this keeps the running and the down time to a minimum.  The scrub tech must know what the physician needs and anticipate this at all times.  All of the instruments must be processed and available as needed.  The CRNA must be able to keep the patient at ease and comfortable during the procedure.

When all of the members of the team work together it shows in other ways also.  Our number one reason for being in the healthcare field – the patient – is pleased and less stressed to be in an unfamiliar environment.  The patient that sees the staff getting along and working together will be able to feel more at ease.

Room turnover time is minimized by each person doing their share in a timely manner.   This can only be accomplished when each staff member takes pride in the job that they do and knows that each duty is an important one.

When all of these people are able to work together to keep the OR organized and running smoothly the physician seems to keep a positive outlook.  This positive outlook can make the whole process a “gentle giant”.

Quality Models

Five years ago, Aetna and several large employers confronted Virginia Mason Medical Center in Seattle over how much it was charging for treatment of migraine, severe acid reflux and narrowed aortic valves, and other conditions. Virginia Mason, a not-for-profit hospital system that employs about 400 salaried physicians, took the message to heart.

Working with the employers and Aetna, doctors and staff began to re-engineer care protocols. For example, the system ensured back pain patients same-day access to a physical therapist and physical medicine physician and sharply reduced medically unnecessary MRI tests and physical therapy visits. From 2004 to 2007, the changes yielded a 50% reduction in lost employee work days due to back pain, almost $2 million in cost savings and high patient satisfaction scores.

Following the overhaul, however, Virginia Mason’s spine clinic was losing revenue because of fewer billed tests and services. To offset the loss, Aetna boosted reimbursement for appropriate physical therapy sessions. With the higher payments and the greater volume of patients it could handle under the more efficient system, Virginia Mason covered its costs—while payers achieved a significant net savings.

President Obama and health policy experts have specifically touted integrated delivery systems, such as Virginia Mason, Geisinger Health System, the Mayo Clinic and others, as national models for innovation. Dartmouth University researchers have found, for instance, that Mayo spends one-third to one-half less than other top hospitals to care for similar patients with equal or better results.

Geisinger has gotten so much attention from politicians that it reportedly hosted tours for more than 70 visiting payers and providers last month.

Leaders of integrated delivery systems say the model won’t work just anywhere. It’s challenging to build a culture of high quality and low costs through contractual relationships. Independent delivery markets don’t have the dynamic of salaried doctors and instead must manage the powerful fee-for-service forces.

Robert S. Mecklenburg, MD, medical director of the Center for Health Care Solutions at Virginia Mason, says his system’s experience shows how health plans and employers can benefit from collaborating with an integrated hospital-physician group. But, he adds, moving away from fee-for-service to payment models that reward better patient outcomes, higher patient satisfaction and lower costs is key.

“[Innovative providers] want to be paid for value,” he says. “That’s very important in straightening out U.S. healthcare.”

Mayo Clinic CEO Dr. Denis Cortese describes integrated systems as having high levels of physician engagement, teamwork, connectivity and greater use of industrial efficiency and quality controls. All this is hard to achieve in contracted networks.

At the same time, experts say, non-integrated systems haven’t felt the pressure—or been given the financial incentive—to change because payers have been slow to revamp payment methods to encourage coordinated delivery. The current fee-for-service model simply rewards greater volume of services.

So far, Dr. Mecklenburg says, no health plans have agreed to pay Virginia Mason based on actual patient outcomes, except on a temporary experimental basis. He believes the system should realize a positive margin when it meets its quality targets.

“You won’t get system reform without changing the reimbursement dynamics,” says Andrew Webber, president of the National Business Coalition on Health in Washington, D.C. “I’m sure the leaders of integrated delivery systems are frustrated with the current payment system.”

ALIGNMENT OF INCENTIVES

At the state level, Massachusetts, with its individual mandate, now is eyeing a shift from fee for service to bundled payments to control spiraling costs.

In line with that, Blue Cross & Blue Shield of Massachusetts continues to leverage its Alternative Quality Contract with episode-based global payments, which pushes providers to work together on improving patient outcomes and cost-effectiveness, according to Jim Conway, senior vice president of the Institute for Healthcare Improvement in Cambridge.

The alternate contract sets specific outcome measures provider groups must achieve in managing patients with chronic conditions. For the first few years, provider groups won’t face financial penalties as long as they meet the process standards, but down the line, they’ll take a financial hit if they don’t meet the outcome targets.

“It took a while for the first hospital and physician group to sign up,” Conway says. “But now a lot of people are signing up because they see this as the direction the industry is going—away from fee for service to a system that takes care of overall global health.”

In other parts of the country, Blue Cross & Blue Shield of Minnesota also has started paying providers for care of the whole patient rather than for specific services, Conway says.

Self-insured employers are testing new reimbursement approaches as well.

Members of the Colorado Business Group on Health are paying providers additional reimbursement on top of fee-for-service payment to manage the care of diabetics and other patients with chronic conditions, according to Webber. They’re using a program developed by the Bridges to Excellence industry partnership. Similarly, the Employers Coalition on Health in Rockford, Ill., is experimenting with paying providers a bundled case rate for patients with chronic conditions, using the PROMETHEUS Payment System, of which Bridges to Excellence is the operational partner.

Webber says health plans and employers should offer financial incentives to patients to get their care from integrated systems, taking advantage of emerging value-based benefit designs.

“There will be opportunities to say to patients, ‘We’re willing to reduce your premium share if you’re willing to participate in more integrated, high-performance delivery systems,’” he says. “I think more and more consumers would be willing to join more closed-panel systems if they could reduce their premium share. Then we can reward high-performance providers in two ways: with payment differentials and with more patients.”

HOME TEAMS

Some health plans and employers around the country are working with provider organizations—and even small physician practices—to support the emerging patient-centered medical home model.

In the model, a primary care physician leads a team of allied health professionals to provide or facilitate each patient’s care needs, including self-care and prevention. The team uses data to proactively manage care for its entire patient population as well.

The Geisinger Health System in Pennsylvania and Group Health Cooperative, a Seattle nonprofit health plan that employs salaried doctors, have reported that their medical home pilots have reduced emergency room use and preventable hospital admissions, improved outcomes for chronic care patients and boosted patient satisfaction. They’re expanding the model to all primary care sites, but it’s costly to properly staff, train and equip practices to become effective medical homes. The practices must be adequately reimbursed to cover the extra patient management services and the forgone fees for service.

Health plans and Medicare have moved slowly on implementing the model, waiting to see evidence of cost savings and quality improvement.

“The medical home is a very important element, and we need to reward primary care doctors, because this can move us toward more integration of care,” Webber says.

Beyond the medical home initiative, Geisinger Health System has taken another step in aligning payment. The not-for-profit system, which includes three hospitals, a multispecialty group practice with 700 doctors and a health plan, is beginning to re-engineer care protocols, starting with coronary artery bypass surgery. Its payment methodology for the re-engineered services, called ProvenCare, bundles comprehensive care for the procedure at a fixed price, instead of piecemeal services and costs. Essentially, by bundling services and paying a flat rate, some risk is shifted to the provider, so it’s in the provider’s interest to deliver the best care, not more care.

Geisinger and its doctors identified 40 factors that produce the best outcomes for bypass operations and built a checklist that ensures those best practices are performed every time. Since its redesign went live early in 2006, Geisinger reports markedly improved patient outcomes for bypass surgery, including a 44% reduction in the 30-day readmission rate, a 21% reduction in patients with any complications, and a 55% reduction in re-operations for bleeding.

Geisinger similarly has redesigned care for hip replacement, interventional cardiology procedures, cataract surgery, obesity surgery and perinatal care.

Duane Davis, MD, chief medical officer of Geisinger Health Plan says Geisinger has gotten a “marketing buzz” out of ProvenCare. Employers like the fact they pay once for the product, just like for other goods and services. But surprisingly, no other health plans have taken Geisinger up on its ProvenCare guarantee deal, except for Geisinger’s own plan. Dr. Davis says he isn’t sure why that’s the case.

“That’s stupid,” says Jeff Goldsmith, a veteran industry forecaster based in Charlottesville, Va. “If a provider group is organized well enough to give you a guarantee they won’t have to readmit, I would rush to sign a contract like that. Maybe some attitudes need to change.”

Goldsmith says that health plans and provider organizations are leery about working together on global payment contracts because of the disastrous experiences with capitated contracts back in the 1990s. Many physician groups and hospitals formed joint ventures to accept these fixed-fee deals and suffered big losses. New structures aim to even out the economics with gainsharing.

WATER UNDER THE BRIDGE

However unfortunate, private practice is collapsing, and more hospitals are employing doctors and creating their own multispecialty, integrated delivery systems. That, Goldsmith says, will allow hospital systems to manage care with their employed doctors. Likewise, health plans may be ready to return to working with provider groups to manage their patient populations because current cost-control methods, such as external utilization review and patient cost-sharing, aren’t sufficient.

“I can’t tell you whether that mindset has changed and whether plans have decided they’ve run out of tricks and are ready to return to working with providers in a constructive way,” Goldsmith says.

Scott Armstrong, president of Group Health Cooperative, says, “our whole industry is in the process of trying to come up with an answer to how health plans can work with providers. How can [global payment] create alignment around common goals? We have to overwhelm the skepticism based on bad experiences in the past.”

Even beyond that, however, Geisinger’s Dr. Davis says it’s going to take time to make healthcare better and cheaper. While integrated systems like his offer important lessons, there are no “big bang” solutions. The primary care medical home is a good place for health plans to start aligning payment incentives for improved care.

“There’s a huge opportunity for the insurance industry to use its skill sets and work in partnership with the clinical side to coordinate very fragmented care,” he says. “If we don’t figure out how to do primary care and coordination better, in the long run, payers will lose anyway.”

While private-industry payers can work on reducing fragmentation, government-supported coverage continues to face budget challenges. As a result, even the highest quality, most efficient providers stand to lose further reimbursement as rates decline.

The Mayo Clinic announced early last month that its Rochester, Minn., clinic, which has treated patients from the Midwest and West, will only accept Medicaid beneficiaries from Minnesota and the four states that border it. Meanwhile, its Arizona location no longer accepts Medicare for patients seeking primary care at its Glendale facility after reviewing results from a two-year pilot project. Mayo leaders made the decisions to limit service based on the low payment rates in Medicare and Medicaid.

We’re All In This Together

As a physician, Reed Tuckson, MD, has seen his share of suffering. He specifically recalls a hospital patient he treated who had congestive heart failure and diabetes. The woman was discharged home, but many social services in her community had been cut, leaving her without meal delivery, transportation or health aid.

When Dr. Tuckson saw her again, she was in the emergency room, septic and malnourished with decubitus ulcers. She had missed every one of her follow up appointments. Medical science could certainly help treat her conditions, however, what the woman truly needed was support beyond the scope of medicine alone.

Dr. Tuckson, who today serves as executive vice president and chief of medical affairs for UnitedHealth Group, believes optimal healthcare delivery requires pulling the pieces of medical and social services together in a comprehensive way, “so that lovely, wonderful woman is not in a wheelchair at two in the morning, unable to breathe, hungry and in pain.” He says the experience with that particular patient still resonates with him.

During his first week on the job with UnitedHealth Group in 2000, he listened in on telephone support calls between care coordinators and plan members and heard them working to solve complex health and social issues not unlike those of his former hospital patient. As he listened in, he heard the insurer’s resources at work. He says the mission to improve health of populations as well as individuals is what drives him.

“The highest level of our mission requires us to find the common connection with the missions of the other stakeholders, because none of us can do alone what actually has to be done on behalf of each individual person,” Dr. Tuckson says. The insurer’s role—which he believes is generally misunderstood by those outside of the industry—is one of collaboration with providers, employers, patients and policymakers. Insurers have experience with the types of value determinations and cost-effectiveness strategies that many are insisting on to reshape the healthcare system overall.

Making Decisions

Dr. Tuckson believes the industry must be more explicit about what patient-centered healthcare delivery should look like and how it should function, then share the vision beyond the purview of its own ranks. That vision isn’t clear enough now to influence change. In order to generate a meaningful conversation that might lead to improvements in the system, the nation must take a long hard look at making choices and engaging consumers, he says.

“What’s so frustrating about the health reform debate in Washington,” he says, “is that it is so completely uninformed about the real issues: How do we make decisions that are personally appropriate that advance our chance for affordable access for the services that we need as individuals—both medical services and medically necessary social services?”

For example, preventive medicine, which many believe can lead to reduced costs and improved health if encouraged more widely, is often dependent on community situations. And the issues are twofold. First, an individual’s community environment plays a role in health. Lack of affordable and healthy food, unsafe neighborhoods and negative media images create inherent challenges to healthy lifestyles. Also, a lack of health clinics to deliver needed prevention can compound the problem.

It’s unreasonable to expect individuals in traditionally underserved populations with little optimism for the future to make healthy lifestyle choices a priority. Many skip preventive health services because they are struggling simply to get a hot meal on the table each night, Dr. Tuckson says.

“If gunshots are ringing through your community, it is very difficult to think about going jogging in the evening or planting a community garden, if there’s no actual earth in which to plant,” he says. “Those are real challenges that are stated the most dramatically.”

It Can Be Done

United Health Foundation, which was established by UnitedHealth Group in 1999, has committed $23 million to four community health centers in Miami, New Orleans, New York City and Washington, D.C., since 2003. Published studies from the George Washington University Medical Center have documented that these clinics, which are located in medically underserved communities, provide high-quality care that equals or exceeds care provided in the private sector, based on national quality benchmarks without risk adjustment.

The clinics have transformed from “centers of last resort to centers of choice,” according to Dr. Tuckson, who serves on the foundation’s board. In September, the university reported that three of the clinics had exceeded the national average of 30% for the percentage of diabetes patients with blood pressure under 130/80 mm Hg. New York (46%), Miami (40%) and New Orleans (39%) beat the benchmark. The same three also exceed the national average of 73% for the percentage of patients with diabetes receiving at least one LDL-cholesterol test—Miami reached 84%, New York reached 82%, and New Orleans reached 98%.

Through innovation, the clinics have been able to serve patients with chronic conditions who need a high level of comprehensive care. There’s no reason why the model of care, which has been able to make the most of scarce resources, should be limited to just one project, one population or to a certain type of coverage category, Dr. Tuckson says.

“The lessons we learn from the health centers ought to be applied to the rest of society and vice versa,” he says.

When considering underserved populations, he also says it’s important to recognize that absolutely every person in every community has a set of unique issues—medical and social—that require multidimensional responses from the healthcare system overall. Individualizing care for each person has become an emerging trend that complements the opportunity for managing care from a population perspective, regardless of what that population might be.

“When it comes to healthcare, it is exceedingly important to realize we’re all in it together,” he says. “The sense of ghetto-izing or segregating certain people, ethnicities or cultures is becoming inappropriate.”

Bringing It All Together

Three emerging factors are accelerating the ability for health plans to push comprehensive care forward:

Improved data analytics now afford opportunities to identify members with a variety of health needs;

Improved health data can also indicate the health needs proactively and with greater specificity; and

Consumerism is increasing members’ engagement levels in their health.

Certainly much of what enables comprehensive care stems from technology, but the tools still have yet to provide for true integration of care delivery among the healthcare silos. While the pace of such progress is frustrating, Dr. Tuckson says the partnership among payers, providers and other stakeholders is helping to overcome the siloed infrastructure more than ever before. The idea of integrated delivery of care has been talked about conceptually for more than a decade, but only now is the healthcare industry beginning to stitch the fragments together, he says.

For example, medical home projects nationwide are bringing care teams together and offering appropriate reimbursement for coordinated clinical approaches. The coordinated approaches are supported by data analytics that provide a snapshot of the comprehensive health needs of each individual person, he says.

“Putting that data into the primary care physician’s office as part of their traditional clinical capabilities and working in partnership allows for more comprehensive management of the individual,” he says. “That’s the next area. That will be defined, obviously, by how fast we can move the health information technology infrastructure.”

UnitedHealth Group launched a patient-centered medical home pilot in February in which it provides technology, infrastructure and care-coordination support to select primary care physicians in Arizona. There are more than 100 medical home pilots underway nationally, and tracking the data over time will inform plans’ future strategies.

Financial Footing

While furthering integrated care, population management and individualization is all well and good, the benevolent side of the mission only tells half the story. Healthcare has become an economic strategy in the United States. The bleak statistics of runaway costs on pace to reach $4 trillion are repeated so often that average Americans have begun to recite them by heart.

Dr. Tuckson says legitimate value determinations are needed to evaluate the relative cost and quality of medical procedures, drugs and devices. Once the value picture is sketched out with some degree of quantification, the individual member or patient is enabled to make clinically and economically smart care choices with his or her providers.

“There has to be a way in which people and society choose what they want and what they are willing to afford within the reality that there has to be controls,” he says. “The easiest part of that conversation would be that people should have access to care that works and is cost-effective. That ought to be a given, however, we also know we have a very suboptimal research infrastructure available to answer that question for expensive and increasingly important interventions, especially given the pace of discovery.”

The genius of America’s inventors and scientists has produced a difficult dilemma in which medical advances that save lives, improve quality of life and reduce pain and suffering also create an unaffordable inflationary spiral. New and improved treatments don’t come cheap. Likewise, the discrete evaluation of emerging procedures and products might prove that each has merit but fails to judge each one’s merit against comparable treatments.

Comparing the effectiveness of treatments head-to-head through scientifically sound research—comparative effectiveness research (CER)—has become cx. Federal health agencies have just begun to dole out $1.1 billion in stimulus funding for CER.

According to Dr. Tuckson, CER will also need to be taken a step further to create protocols in real-world clinical practice based on research results. He says CER funding is promising but it’s not likely to produce the scope of research needed nor the speed at which it must be delivered to improve the health of Americans affordably. His plea is that stakeholders fight “so much harder for the research infrastructure that delivers the answers to these questions.”

Clinical Expertise

Once the federally sponsored CER begins drawing conclusions, specialty societies, such as the American Academy of Pediatrics for example, could then take a lead role in translating research into best practices then in communicating the guidance to physicians. Specialty societies will need more support for that to happen, however, because they currently don’t have the resources to turn that kind information around in a timely manner.

“It is terribly inappropriate to leave those kind of choices to our industry, uninformed by the best of our nation’s clinical science expertise,” Dr. Tuckson says. “At United, we put our money where our mouth is by putting money into these societies, but with the level of scale that’s needed, no one company can do this by itself.”

He says he is “deeply saddened” when health insurers use their experience to make value decisions, then are criticized for it. Other stakeholders need to be involved, and he says he looks forward to having honest conversations at the national level to address the shared goals of value determinations and controlling the rising cost trends.

No one wants their insurer to exclude any service from the benefit package, Dr. Tuckson says, but on the other hand, no one is pleased by the amount of waste and misuse of services that are prevalent in the U.S. system. The fundamental contradiction of these two attitudes have become more evident in recent policy discussions. It makes for a frustrating process when trying to bend the cost curve and design benefits appropriately.

That’s why Dr. Tuckson believes when it comes to healthcare, everyone is in it together. No matter what operational challenges health plans must confront, sensible contracting, providing affordable access, and maintaining dynamic partnerships with providers and community organizations remain the plans’ responsibility.

“All pieces of that puzzle must all work together,” he says. “And we have to be part of that, acting on behalf of the needs of the person. If we lose sight of that, we do so at our peril.”

Reed Tuckson, MD, on…

The politics of health reform

“Health reform is talked about almost as if it were a political football game, and you’re either on one side or you’re on another. People use terms—public plan, health exchange, single payer—and that sort of lets you know if you’re on this team or that team…I refuse to be on any of those teams. It’s silliness.”

Holding down costs

“You have to get at controlling the inflation of unit costs for physician and hospital reimbursement. You have to get at the issue of appropriateness in the access to services and controlling waste and inefficiency in the delivery.”

Health insurers as stakeholders

“We in our industry clearly understand what it means to try to control unit costs and be fair to the hospitals and physicians who are delivering the care. We absolutely understand what it means to try and take the waste out of the system and all the challenges that come from doing that every day. We also know the anger and the frustration that occurs when you do it. We bring a set of experiential knowledge that is essential when trying to find solutions to problems, more so than anyone.”

Health insurance exchanges

“The health insurance exchange concept today as discussed is a philosophical placeholder for a political or social agenda, as opposed to being something that everyone understands what it means, how it would work and the ways in which it is going to deal with the two fundamental issues on the table: How will it deal with unit cost pricing and how will it deal with utilization and the control of utilization of healthcare services?”

Expansion of Medicaid

“Expanding Medicaid, public insurance, is an important part of the mosaic. It will take a mosaic to achieve our goals, and public insurance is going to be very important in that regard, just as private insurance will be important in that regard.”

Insurers being called ‘dishonest’

“When it comes to health and human survival, this is a profound social ethic that requires and demands the best of all of us. To deliberately and mean-spiritedly deny the participation and challenge the ethical integrity of a major stakeholder in the solution to this problem is to do potential violence to the opportunity for optimal solutions and thereby optimal health of the nation.”
Reed Tuckson, MD, UnitedHealth Group, Executive Vice President and Chief of Medical Affairs
Reed Tuckson, MD, has more than 25 years of experience in healthcare leadership and has been a member of several bipartisan federal advisory committees on genetics, infant mortality, children’s health, violence, radiation testing and healthcare reform. Previously he served as senior vice president for professional standards for the American Medical Assn. In February, Black Enterprise named him one of the “100 Most Powerful Executives in Corporate America.” He earned a bachelor’s degree in zoology from Howard University and his medical degree from the Georgetown University School of Medicine.

Staying Motivated & Proactive in Today’s Ophthalmic World

Elective case volumes are down in this poor economy; government healthcare plan is reducing Medicare reimbursements even further; and your house hasn’t recovered in value since the 2008-09 real estate down turn. What’s a healthcare person to do?!?  

Like our forefathers, we need to adapt and modify the way in which we do business and expend monies during poor economic times. Perhaps to counter the decrease in cases, you might look to provide added value services to your patients. An example would be to provide hearing tests and hearing aids to your patients. To elaborate on hearing services, here are some little known facts; (1)  50%+ of all senior citizens have significant hearing loss, (2) 80% of them have never been tested for such loss, and (3) hearing aids are the only effective treatment for 90% of such patients.  So think about it — for every 100 patients who come through your waiting room, 50 of these patients have a hearing problem and 40 have done nothing to address it. Baby-boomers’ hearing loss is far greater than earlier generations. Plus, this group is more apt to seek treatment. Hearing services could prove to be a natural fit in ophthalmology.

Another step forward would be to engage the creative side of you & your staff by having brainstorming sessions with your key people. The objective for these meetings would be to come up with ideas for added services, ways to improve efficiencies, and areas for cost cutting.

Most importantly, remember to focus on your blessings, not your misfortunes. It’s a known fact that positive people are more successful (and with less health problems) than negative thinkers. If you have difficulty staying positive, I would encourage you to give yourself daily pep talks and keep telling yourself “I can’t change this bad situation, but I can certainly change my attitude toward it.”

We’re All In This Together

As a physician, Reed Tuckson, MD, has seen his share of suffering. He specifically recalls a hospital patient he treated who had congestive heart failure and diabetes. The woman was discharged home, but many social services in her community had been cut, leaving her without meal delivery, transportation or health aid.

When Dr. Tuckson saw her again, she was in the emergency room, septic and malnourished with decubitus ulcers. She had missed every one of her follow up appointments. Medical science could certainly help treat her conditions, however, what the woman truly needed was support beyond the scope of medicine alone.

Dr. Tuckson, who today serves as executive vice president and chief of medical affairs for UnitedHealth Group, believes optimal healthcare delivery requires pulling the pieces of medical and social services together in a comprehensive way, “so that lovely, wonderful woman is not in a wheelchair at two in the morning, unable to breathe, hungry and in pain.” He says the experience with that particular patient still resonates with him.

During his first week on the job with UnitedHealth Group in 2000, he listened in on telephone support calls between care coordinators and plan members and heard them working to solve complex health and social issues not unlike those of his former hospital patient. As he listened in, he heard the insurer’s resources at work. He says the mission to improve health of populations as well as individuals is what drives him.

“The highest level of our mission requires us to find the common connection with the missions of the other stakeholders, because none of us can do alone what actually has to be done on behalf of each individual person,” Dr. Tuckson says.

The insurer’s role—which he believes is generally misunderstood by those outside of the industry—is one of collaboration with providers, employers, patients and policymakers. Insurers have experience with the types of value determinations and cost-effectiveness strategies that many are insisting on to reshape the healthcare system overall.

Making Decisions

Dr. Tuckson believes the industry must be more explicit about what patient-centered healthcare delivery should look like and how it should function, then share the vision beyond the purview of its own ranks. That vision isn’t clear enough now to influence change. In order to generate a meaningful conversation that might lead to improvements in the system, the nation must take a long hard look at making choices and engaging consumers, he says.

“What’s so frustrating about the health reform debate in Washington,” he says, “is that it is so completely uninformed about the real issues: How do we make decisions that are personally appropriate that advance our chance for affordable access for the services that we need as individuals—both medical services and medically necessary social services?”

For example, preventive medicine, which many believe can lead to reduced costs and improved health if encouraged more widely, is often dependent on community situations. And the issues are twofold. First, an individual’s community environment plays a role in health. Lack of affordable and healthy food, unsafe neighborhoods and negative media images create inherent challenges to healthy lifestyles. Also, a lack of health clinics to deliver needed prevention can compound the problem.

It’s unreasonable to expect individuals in traditionally underserved populations with little optimism for the future to make healthy lifestyle choices a priority. Many skip preventive health services because they are struggling simply to get a hot meal on the table each night, Dr. Tuckson says.

“If gunshots are ringing through your community, it is very difficult to think about going jogging in the evening or planting a community garden, if there’s no actual earth in which to plant,” he says. “Those are real challenges that are stated the most dramatically.”

It Can Be Done

United Health Foundation, which was established by UnitedHealth Group in 1999, has committed $23 million to four community health centers in Miami, New Orleans, New York City and Washington, D.C., since 2003. Published studies from the George Washington University Medical Center have documented that these clinics, which are located in medically underserved communities, provide high-quality care that equals or exceeds care provided in the private sector, based on national quality benchmarks without risk adjustment.

The clinics have transformed from “centers of last resort to centers of choice,” according to Dr. Tuckson, who serves on the foundation’s board. In September, the university reported that three of the clinics had exceeded the national average of 30% for the percentage of diabetes patients with blood pressure under 130/80 mm Hg. New York (46%), Miami (40%) and New Orleans (39%) beat the benchmark. The same three also exceed the national average of 73% for the percentage of patients with diabetes receiving at least one LDL-cholesterol test—Miami reached 84%, New York reached 82%, and New Orleans reached 98%.

Through innovation, the clinics have been able to serve patients with chronic conditions who need a high level of comprehensive care. There’s no reason why the model of care, which has been able to make the most of scarce resources, should be limited to just one project, one population or to a certain type of coverage category, Dr. Tuckson says.

“The lessons we learn from the health centers ought to be applied to the rest of society and vice versa,” he says.

When considering underserved populations, he also says it’s important to recognize that absolutely every person in every community has a set of unique issues—medical and social—that require multidimensional responses from the healthcare system overall. Individualizing care for each person has become an emerging trend that complements the opportunity for managing care from a population perspective, regardless of what that population might be.

“When it comes to healthcare, it is exceedingly important to realize we’re all in it together,” he says. “The sense of ghetto-izing or segregating certain people, ethnicities or cultures is becoming inappropriate.”

Bringing It All Together

Three emerging factors are accelerating the ability for health plans to push comprehensive care forward:

Improved data analytics now afford opportunities to identify members with a variety of health needs;

Improved health data can also indicate the health needs proactively and with greater specificity; and

Consumerism is increasing members’ engagement levels in their health.

Certainly much of what enables comprehensive care stems from technology, but the tools still have yet to provide for true integration of care delivery among the healthcare silos. While the pace of such progress is frustrating, Dr. Tuckson says the partnership among payers, providers and other stakeholders is helping to overcome the siloed infrastructure more than ever before. The idea of integrated delivery of care has been talked about conceptually for more than a decade, but only now is the healthcare industry beginning to stitch the fragments together, he says.

For example, medical home projects nationwide are bringing care teams together and offering appropriate reimbursement for coordinated clinical approaches. The coordinated approaches are supported by data analytics that provide a snapshot of the comprehensive health needs of each individual person, he says.

“Putting that data into the primary care physician’s office as part of their traditional clinical capabilities and working in partnership allows for more comprehensive management of the individual,” he says. “That’s the next area. That will be defined, obviously, by how fast we can move the health information technology infrastructure.”

UnitedHealth Group launched a patient-centered medical home pilot in February in which it provides technology, infrastructure and care-coordination support to select primary care physicians in Arizona. There are more than 100 medical home pilots underway nationally, and tracking the data over time will inform plans’ future strategies.

Financial Footing

While furthering integrated care, population management and individualization is all well and good, the benevolent side of the mission only tells half the story. Healthcare has become an economic strategy in the United States. The bleak statistics of runaway costs on pace to reach $4 trillion are repeated so often that average Americans have begun to recite them by heart.

Dr. Tuckson says legitimate value determinations are needed to evaluate the relative cost and quality of medical procedures, drugs and devices. Once the value picture is sketched out with some degree of quantification, the individual member or patient is enabled to make clinically and economically smart care choices with his or her providers.

“There has to be a way in which people and society choose what they want and what they are willing to afford within the reality that there has to be controls,” he says. “The easiest part of that conversation would be that people should have access to care that works and is cost-effective. That ought to be a given, however, we also know we have a very suboptimal research infrastructure available to answer that question for expensive and increasingly important interventions, especially given the pace of discovery.”

The genius of America’s inventors and scientists has produced a difficult dilemma in which medical advances that save lives, improve quality of life and reduce pain and suffering also create an unaffordable inflationary spiral. New and improved treatments don’t come cheap. Likewise, the discrete evaluation of emerging procedures and products might prove that each has merit but fails to judge each one’s merit against comparable treatments.

Comparing the effectiveness of treatments head-to-head through scientifically sound research—comparative effectiveness research (CER)—has become cx. Federal health agencies have just begun to dole out $1.1 billion in stimulus funding for CER.

According to Dr. Tuckson, CER will also need to be taken a step further to create protocols in real-world clinical practice based on research results. He says CER funding is promising but it’s not likely to produce the scope of research needed nor the speed at which it must be delivered to improve the health of Americans affordably. His plea is that stakeholders fight “so much harder for the research infrastructure that delivers the answers to these questions.”

Clinical Expertise

Once the federally sponsored CER begins drawing conclusions, specialty societies, such as the American Academy of Pediatrics for example, could then take a lead role in translating research into best practices then in communicating the guidance to physicians. Specialty societies will need more support for that to happen, however, because they currently don’t have the resources to turn that kind information around in a timely manner.

“It is terribly inappropriate to leave those kind of choices to our industry, uninformed by the best of our nation’s clinical science expertise,” Dr. Tuckson says. “At United, we put our money where our mouth is by putting money into these societies, but with the level of scale that’s needed, no one company can do this by itself.”

He says he is “deeply saddened” when health insurers use their experience to make value decisions, then are criticized for it. Other stakeholders need to be involved, and he says he looks forward to having honest conversations at the national level to address the shared goals of value determinations and controlling the rising cost trends.

No one wants their insurer to exclude any service from the benefit package, Dr. Tuckson says, but on the other hand, no one is pleased by the amount of waste and misuse of services that are prevalent in the U.S. system. The fundamental contradiction of these two attitudes have become more evident in recent policy discussions. It makes for a frustrating process when trying to bend the cost curve and design benefits appropriately.

That’s why Dr. Tuckson believes when it comes to healthcare, everyone is in it together. No matter what operational challenges health plans must confront, sensible contracting, providing affordable access, and maintaining dynamic partnerships with providers and community organizations remain the plans’ responsibility.

“All pieces of that puzzle must all work together,” he says. “And we have to be part of that, acting on behalf of the needs of the person. If we lose sight of that, we do so at our peril.”

Reed Tuckson, MD, on…

The politics of health reform

“Health reform is talked about almost as if it were a political football game, and you’re either on one side or you’re on another. People use terms—public plan, health exchange, single payer—and that sort of lets you know if you’re on this team or that team…I refuse to be on any of those teams. It’s silliness.”

Holding down costs

“You have to get at controlling the inflation of unit costs for physician and hospital reimbursement. You have to get at the issue of appropriateness in the access to services and controlling waste and inefficiency in the delivery.”

Health insurers as stakeholders

“We in our industry clearly understand what it means to try to control unit costs and be fair to the hospitals and physicians who are delivering the care. We absolutely understand what it means to try and take the waste out of the system and all the challenges that come from doing that every day. We also know the anger and the frustration that occurs when you do it. We bring a set of experiential knowledge that is essential when trying to find solutions to problems, more so than anyone.”

Health insurance exchanges

“The health insurance exchange concept today as discussed is a philosophical placeholder for a political or social agenda, as opposed to being something that everyone understands what it means, how it would work and the ways in which it is going to deal with the two fundamental issues on the table: How will it deal with unit cost pricing and how will it deal with utilization and the control of utilization of healthcare services?”

Expansion of Medicaid

“Expanding Medicaid, public insurance, is an important part of the mosaic. It will take a mosaic to achieve our goals, and public insurance is going to be very important in that regard, just as private insurance will be important in that regard.”

Insurers being called ‘dishonest’

“When it comes to health and human survival, this is a profound social ethic that requires and demands the best of all of us. To deliberately and mean-spiritedly deny the participation and challenge the ethical integrity of a major stakeholder in the solution to this problem is to do potential violence to the opportunity for optimal solutions and thereby optimal health of the nation.”

Giving Back

On the surface, Kenny Spitler and Marcy Sasso would seem to be from two different mindsets, let alone two different parts of the country. But each has a passion for giving back to their communities — in two distinct ways — that can be infectious. And both stress the importance for ASCs to get involved in their local communities.

“We’re in the healthcare industry and in particular, in economic times that are tough as what we’ve been going through, the healthcare industry has still been strong,” says Spitler, senior vice president of development for HealthMark Partners in Nashville, Tenn. “So giving back to the community is essential, in my mind.”

Sasso, director of operations at the ASC of Union County, in Union Township, N.J., explains that giving back is paramount for ASCs, and not just to serve the community, either. “We as surgery centers, are often thought of as ‘cherry pickers,’ that we take the best cases from the hospitals. But we can provide exemplary service to everyone involved, physicians as well as patients.”

ASCs 2009

Spitler was given the task of organizing a volunteer project as part of the Ambulatory Surgery Center Association’s 2009 annual meeting held in Nashville last April. Previous projects had volunteers planting sunflower seeds in New Orleans to remove lead that had seeped into the soil around the city after Hurricane Katrina, and cleaning up the grounds at the Fisher House in the Brooke Army Medical Center in San Antonio, Texas. But he wanted to do something that would give some tangible results to the volunteers participating.

“My biggest goal was I wanted to do something that’s going to endure,” notes Spitler. “I wanted something that would have a little more lasting effect for the Association.”

So he took 20 to 25 volunteers apiece in two shifts and went over to the Boys & Girls Clubs of Middle Tennessee in nearby Antioch, to help decorate and landscape an outdoor play area for the 105 children who utilize their afterschool program. The groups built and stained benches and picnic tables, installed bird feeders and a bird bath, planted shrubs and flowers, and prepared a vegetable garden for the children to grow their own vegetables.”

“What they did was a fantastic beautification process,” states John Hamilton, Club director of the Boys & Girls Clubs of Middle Tennessee, “one (that) the kids really love and the community sees it, too.”

And the impact on the children was almost immediate, says Hamilton. “I have heard the children say a few times since then, ‘This is our Club now. This is our home now because it looks like a Boys & Girls Club.’”

“Doing the work was great, but seeing the kids’ faces after it was all done, was really what it was all about,” Spitler declares. “Just complete joy.”

Hamilton also notes the enthusiasm of the volunteers was a key in making the project a success. “They really took the project, and were gung ho (about it.) They began work from the time they got off the bus, until the time they had to leave.”

“We probably wouldn’t have gotten this project done if it wasn’t for them, based on the economy and funding,” says Bob Jacobs, vice president of resource development for the Boys & Girls Clubs of Middle Tennessee. He also points out that so much of this type of service relies on volunteers, which translates into these same children becoming more involved in these types of projects in the future.

Health Fair

When Sasso learned that Union Township, N.J., no longer had its annual community health fair due to the local hospital closing 18 months ago, she saw an opportunity for her ASC to get involved.

“Within three days, I had a unanimous vote from the owners to green light hosting the health fair,” says Sasso. The success of the health fair was due to the participation of physicians, staff members, family members and the Gateway Chamber of Commerce. “It turned a marketing event into an opportunity for saving lives and providing education for the community. The health fair was organized within a two month time frame, although she feels that six months preparation is optimal.

Sasso’s infectious attitude was able to rub off on to the community, where many of the medical and healthcare-related organizations contributed to the event. Twenty booths displayed health screenings, visual demonstrations for surgeries, fingerprinting and bike safety information for children, and most importantly, the chance for her ASC physicians to interact with the community.

“I had a woman tell me afterward that she was so grateful to talk with one of our surgeons for 15 minutes,” Sasso articulates. “Most people don’t get that amount of time, even in a consultation.”

In the end, hundreds of attendees paid a visit to the health fair over an afternoon that gave Sasso plenty of ideas on how to make next year’s event an even greater success.

“If anything, I think if I had six months to prepare, it will make a tremendous difference. I can attract more groups that weren’t able to participate this year,” she reveals. “We just have to communicate to various agencies to attract a broader audience, which of course we will. “This will definitely become an annual event for the ASC Give Back! I know it changed people’s lives. The staff feels very proud of the interaction and positive response from the community.”

Getting Involved

Spitler feels there needs to be a continued effort nationally from the ASC industry to participate in volunteering events like his. “If asked, most of the people in the industry are willing to give back. If there were an ongoing effort to perpetually do something from a charitable standpoint from the industry as a whole, I think it would be well received.”

He points to an event at this year’s annual meeting as an example. A couple of volunteers from the project were given the chance to speak to the general audience, asking for donations for the Boys & Girls Clubs. “There was $2,800 collected that day for the Boys & Girls Clubs,” says Spitler. “Another group bought toys and other items for the club.”

For local ASCs, Sasso suggests to start small. “You always have a little bit to give. Even if you don’t think you have the time, once you start this, hopefully you’ll have the same feelings that my staff and I have.” To go along with the health fair, the ASC of Union County has participated in such things as holiday toy drives, walks for autism and breast cancer patients, a bike ride for multiple sclerosis.

“Giving is such a contagious thing,” Sasso says.

Importance of a Positive Attitude and Other Health News

A Positive Attitude Might Improve Your Health, Longevity

Women who are optimistic about life live longer and are healthier than those who are pessimistic, according to a new study presented last week at the American Psychosomatic Society’s annual meeting. And women who tend to be more trusting of others live longer than those who are more cynical, according to the Boston Globe’s report on the study. These new findings come from the Women’s Health Initiative, a clinical trial of more than 97,000 healthy women ages 50 to 74 that is widely known for its research into hormone therapy. Optimistic women had a 14 percent lower risk of death from any cause after eight years than those who were more pessimistic. More cynical women had a 16 percent higher risk of dying than more trusting women. The study does not prove that attitudes affect health or cause illness, but the association is worth further research, according to the Globe .

This isn’t the first time that research has linked having a positive attitude to longer life span. Happier people are less likely to suffer heart attacks, strokes, and pain from conditions like rheumatoid arthritis. If the recession has you feeling down, consider these 5 ways to be happy during bad economic times.

If Diets Don’t Work, What’s the Solution to Obesity inAmerica?

For most people, diets simply don’t work. The latest evidence: a recent study published in the New England Journal of Medicine examining diets with different proportions of carbohydrates, protein, and fat. Not surprisingly, it made no difference what kind of diet people followed; if they reduced calories, they initially lost weight, Katherine Hobson reports. But after two years, average participants had regained weight, leaving them with a net loss of just 9 pounds—and on a path toward further regain. A similar study published in 2007 also found that dieters regained weight regardless of their regime. A small portion of dieters do manage to keep weight off; about 15 percent of participants in the NEJM study dropped at least 10 percent of their body weight.

Consider these 7 tips to shed pounds and these 9 lessons that may help end yo-yo dieting. Still, not all diets are worthless. These 4 distinct diet styles, including the Mediterranean diet, have long promoted better health.

Swimming Lessons Really Do Keep Kids Safer

Young children are less likely to drown if they’ve taken swimming lessons, according to researchers at the National Institute of Child Health and Human Development. That’s good news, since drowning is the leading cause of fatal injury in children ages 1 to 4, Nancy Shute reports. Formal swimming lessons for preschoolers reduce their risk of drowning by 88 percent, the researchers found. This is the first scientific look into whether early childhood swimming lessons reduce the risk of drowning, although mom listservs abound with questions on the value of swimming lessons vs. “drownproofing” classes. The results were reported in the Archives of Pediatric and Adolescent Medicine.

Swimming can be loads of fun for kids and adults alike. For the older set, here is how one 70-year-old man trained for a very long swim.

Promote Looking and Performing Your Best in the OR

“You only have one opportunity to make a first impression”

 

-Anonymous

IMAGE matters.  It has been stated, be it good or bad, that a person will make an impression within the first seven seconds of being in front of a customer.  This also applies to all of us who work with Patients as well.  A sloppy, unkempt surgical team promotes an image of a staff that is careless and unconcerned about patient care and infection control. 

Most of us already have Dress Code policies in place however many of us are not enforcing them.  Developing a policy is a noble and necessary task but if we implement and do not enforce our policies they are virtually useless.  Moreover, if our surgical attire policies are not followed by our employees then we are actually putting patients at risk as well.  Remember, that many contributors of patient infection can be found in our hair, skin, etc.

The best way to begin enforcement of policies is to plan, audit, and communicate.  First of all, plan inspections and set benchmarks.  Keep your inspections random and unannounced and set your benchmarks for a 100% compliance since the importance of this issue is paramount.  Next, audit the data you collect.  Analyze and locate areas for improvements and be sure to notice the areas where compliance has already been met.  Finally, communicate the results of your analysis to the staff members.  This will create a sense of “buy in” to the policy and show your dedication to making progress and changes within your surgical department.

If you need help in developing an auditing tool there are a number of resources to seek out.  For example, Outpatient Surgery Magazine has a great start to creating an auditing tool in the June 2008 issue.  It touches on the fundamentals of proper surgical attire such as the condition and appearance of the scrubs, hair maintenance, and jewelry confinement, as well as other personal grooming issues.  Tools like these will make your auditing and analysis less burdensome and give you more time to focus on the other needs of your department.

By following these simple principles, the image of your surgical team will improve and hopefully by your staff looking and feeling good about themselves, job performance will naturally improve as well.  Remember that IMAGE matters, and IMAGE can also change attitudes.

Acceptable Vendor Etiquette

Ever have a sales rep arrive at your facility unannounced or with an attitude that he/she owns the place? Don’t allow this to happen! If you do, it’s your own fault for not establishing ground rules with your doctors, OR staff, front desk people and the sales reps themselves.

Doctors are known to invite sales reps in without notifying facility management. If this is happening at your facility, I strongly encourage you to sit down with your surgeons and agree upon policies and procedures with regard to sales reps visiting your ORs.  Once these rules are established in writing, make certain to educate your OR and front office staff and emphasis the importance of their adhering and enforcing these procedures.

What’s acceptable? For one, sales reps should never be allowed to walk into your OR unannounced and without permission from the facility manager or director of surgery, as well as your surgeon.  I don’t care how good a friend the sales rep is with the surgeon – prior approval to visit your facility is a must. As a general rule, here is a list of acceptable vendor etiquette that all reps should be required to follow when visiting your facility:

• Prior to arrival, sales rep should:
  • Set up an appointment with facility manager at least 5 days prior to arrival.
  • Confirm with facility manager the appointment date/time and that surgeon & OR staff are aware that sales rep will be observing surgeries on that particular day.
  • Provide facility manager with evidence that rep has been properly trained and are fully acknowledgeable on OR procedures, sterile technique, infection control and HIPAA requirements.
• Day rep arrives at facility, sales rep must
  • Check-in at front desk by signing a vendor visitation form stating rep’s name, company, date and time of arrival, name of surgeon visited, and purpose of meeting.
  • Read the facility’s vendor visitation policy and acknowledge that he/she will follow any and all policies at all times during the visit. This policy should be in writing and part of the vendor visitation form.
  • Give front desk staff, his/her driver’s license, car keys, cell phone and/or pager. This personal item must be picked up at the end of rep’s appointment as a means to ensure the rep properly checks out of facility, signs and records his/her time of departure on the vendor visitation form.
  • Allow front desk staff to alert Facility Manager and/or Director of Surgery that rep has arrived.
  • Be escorted by front office staff to changing room and dress in specially provided scrubs which distinguishes the rep from all facility staff. This should be a set of scrubs or scrub cap that is different in color from rest of the staff and surgeons.
  • Proceed to nurses station and introduce him/herself to the RN in-charge of OR that day

Do yourself and your facility a favor and require all sales reps to strictly adhere to these standards. In doing so, your facility will be safer, your staff happier and your surgeon and vendor relations stronger.

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