Posted on December 15, 2011 by Craig Becker
When my boys were younger, my wife used to chastise me for getting too many presents for my two boys. Of course, the more toys I bought, the more my boys came to expect. It was a toys arms race I couldn’t win. More importantly, it was the wrong message to send to my children.
Two years ago, Tennessee hospitals began voluntarily assessing themselves on a temporary basis to bail the state out of a bad revenue situation. Of course, the more we have assessed hospitals, the more the state wants.
Once again, the THA board of directors has stepped up and given the state of Tennessee an early and significant Christmas present by indicating it would continue the hospital coverage assessment in 2012 to keep the TennCare program alive. Apparently, it isn’t enough from the state’s perspective. We were informed the state is looking at possibly cutting hospitals and other providers by another 5 percent. On top of that, other groups want THA to raise the assessment to the maximum to fund their projects.
In 2010, Tennessee hospitals’ gift to the state was $349 million, while in 2011, the bow was around a $450 million package for a grand total of $799 million in two years – all dollars the state should be paying. But the gift giving isn’t over just with the assessment. Tennessee hospitals provided another whopping $1.1 billion in uncompensated charity care costs in 2010 alone.
While THA has agreed to help fund the program this year, it will advocate to the legislature and administration that the assessment should remain at the 2011 level of 4.52 percent or be decreased. Tennessee hospitals should not be asked to increase the assessment especially when the state has seen an increase in its revenue picture. We believe some of those dollars should go towards increasing the state’s share of the TennCare program.
Congress, which in all likelihood will play the role of Grinch in the next budget round, already has stated it will reduce the allowable percentage a state can collect for these assessments. As a result of this looming uncertainty, it would be prudent for the state to keep the percentage the same as last year or lower it.
Health care is about to undergo a huge sea change. Santa might not have a full bag as he once did. Hospitals can’t be expected to continue to carry both an assessment and charity care burden.
Now that I am older, wiser and listen to my wife, my boys are down to fewer gifts. Of course, bigger boys need bigger toys, so I am not sure I am saving that much. But I do know my boys aren’t taught responsibility with more gifts.
Posted on October 19, 2011 by Craig Becker
I often have heard the term, “We will have to do more for less,” meaning hospitals will be expected to provide the same level of care and get paid less.
With congress cutting our payments, but not the benefits we must provide, obviously this is a losing proposition for hospitals. The only way to do more for less is to provide fewer services and cut access to care.
Actually, I think hospitals will have to provide less for less.
What I mean by this is in the future, hospitals will be paid in a bundled payment or capitation style. No longer will they make their margins by doing more operations, tests and admissions. They will be doing fewer tests, operations and admissions. In other words, hospitals will be providing the most appropriate care.
Too often, evidence-based medicine is ignored or not implemented at all. Defensive medicine also contributes to more care. Volume-driven payment systems, in particular, contribute to the cost and waste in health care. I would argue we also need to do less interventions and the quality of care and patient safety would improve.
We have all heard the stories of seniors and the chronically ill coming into the hospital with 20 or 30 prescriptions, many of which are contraindicated. Polypharmacy is rampant and contributes mightily to the cost of care. Most recently, studies have shown PSAs and mammograms do little to save lives and, in fact, increase the likelihood that men and women’s quality of life may be negatively impacted with little to show for it.
I realize these are all emotional issues, but if we are to get our arms around healthcare costs, hospitals are going to have to start implementing and believing in evidence-based medicine. More care is not necessarily good care. In fact, the worst care you can give someone is care not needed.
We are heading into a tumultuous time in health care. We are going to figure out how to provide less care for fewer dollars. This will take a major mind shift among CEOs, board members and medical staffs.
There is no time to lose. We must start doing it now.
Posted on September 13, 2011 by Craig Becker
Ten years ago this past Sunday, terrorists inspired by Osama Bin Laden flew planes into the World Trade Center and the Pentagon. Another flight crashed into a field in Pennsylvania after its passengers rushed the cockpit to stop the hijackers from crashing into another U.S. building.
By coincidence, I was landing at Reagan Airport in Washington, DC, to attend a meeting at the American Hospital Association just as the first plane was flying into the World Trade Center. As I sat in the cab, listening to the news reports, my cabbie and I saw a plane slowly circling Washington. Both of us commented on how low it was flying, but just assumed he was landing at the airport. A short time later, as we passed by the Pentagon, we saw a huge fireball as that plane crashed into the building.
Needless to say, this was a life changing experience for me, making me appreciate life all the more. Another teaching moment for me was how the country came together as never before, except for Pearl Harbor, and for one brief shining moment, we were single-minded and working together as a country. The lesson not lost on me was how much better the country is when we are working together instead of being splintered.
Of course, a brief decade later, we are as polarized as we were together as a country. Congressional members cannot even talk to each other without getting into elementary recess playground fights. Nothing is getting done and our stature in the world is quickly eroding.
I have been blessed with being the president of an association that has worked together for the past 19 years. As I like to say, we check our guns at the door of the board room and make decisions that are best for ALL Tennessee hospitals and the patients they serve.
We just had another example of that at our recent board meeting. We have spent two years working towards a compromise on variation in TennCare rates, a very divisive and difficult discussion. The board spent three hours working on a compromise. We aren’t there yet, but we are close. If this were congress or even some other states, we would have seen hard and fast positions and nothing would have gotten done.
I so appreciate all of my members and their willingness to talk and compromise.
I only hope we can keep this spirit alive and pray our country will go back to those heady days just after 9/11.
Posted on August 1, 2011 by Craig Becker
About 230 years ago, the British, under Lord George Cornwallis, surrendered to the rag tag Continental Army lead by General George Washington. Of course, he had a little help from his friends, the French.
As the British troops were marching out to drop their weapons and board ships to take them home, the British band played a song called, “The World Turned Upside Down.” To the mighty British, it was impossible for them to think they could lose to a bunch of frontiersmen. To them, their world had been truly turned upside down.
We in health care are starting to hear the same drumbeat of a world turned upside down. The current deficit reduction debate in Washington will surely mean fewer dollars for hospitals. THA has estimated if congress carries out its stated goal of reducing hospital payments between $100 and $300 billion, Tennessee hospitals eventually will see a decrease of 15 to 45 percent in their Medicare and TennCare revenues. As I recently told Tennessee’s congressional delegation, I can’t even get my arms around those kinds of numbers. But get our arms and minds around these drastic cuts we must.
We just ended our annual summer conference and 150 of your peers heard speaker after speaker talk about the coming Armageddon. Nate Kaufman very eloquently laid out the coming storm. Connie Curran talked about the role of the trustee in assuring we still have a medical system in place to provide care. Only Joe Tye was the Pollyanna of the group, stating out of chaos comes something better.
I happen to agree with Joe. We all knew this day was coming. It is a shame that it took an act of congress for us to start doing the right thing – watching our costs, putting together a true medical care system and, most importantly, get our quality and patient safety right.
While our world may be turned upside down, I believe we will come out stronger with a better system of care. After Cornwallis’ surrender, the revolution raged on for two more years, but in the end, America was born, the ideals of freedom and equality emerged, and a whole new way of governing that the world couldn’t have imagined came on the scene.
I, for one, see the same for our healthcare system.
Posted on July 11, 2011 by Craig Becker
I have been in this business a long time and I am considered by many to be an archivist. I think it means I am old.
In any event, I feel like we are going through déjà vu’ all over again. Our friends in congress, as they did back in 1997, have decided to balance the budget on hospitals’ backs. I am in no way saying we shouldn’t shoulder our share of the burden, but what is being discussed is just down right frightening and not right.
Under the recently passed healthcare reform law, hospitals are expected to put up $155 billion in cuts, which already are in place. Of course, that was to be offset by increased coverage. Various proposals endorsed by the Republicans would repeal the mandate, but keep the cuts, devastating enough. However, now there are reports that the administration and congress are talking about a deal to take literally trillions out of the budget, with the bulk of it coming from Medicare and Medicaid.
An analysis by THA shows the dramatic impact of the $155 billion reduction, which has me shaking my head to figure out how hospitals will be able to deal with those cuts. Now, with congress and the administration piling on more cuts, I know we will see some hospitals close and surely we will see services curbed and layoffs aplenty.
What has me scratching my head is this is similar to 1997 when the Balanced Budget Act (BBA) was passed. For three years, hospitals endured the cuts through layoffs and curbed services. Congress finally saw the light and restored many of those cuts. Why congress and the administration would call for these drastic cuts is beyond me, knowing Tennessee hospitals will have to cut quite a few of their 98,000 jobs while safety net hospitals will struggle to stay open and keep losing money in an effort to provide needed services.
Is this déjà vu all over again? Will congress cut and then restore funding a few years later when the damage is done? I, for one, am not waiting to see if that happens.
THA has been working hard to convince Tennessee’s congressional delegation to be prudent in its cuts to providers. There is only so much that can be cut before we see the Armageddon I described above. What hospitals need to do is to make more noise and tell their elected officials just what the impact will be on their individual institutions. If everyone stays quiet, they surely will think hospitals can handle these draconian cuts.
I may be the archivist, but I am not too old to know what these proposed cuts will do to hospitals and the people they serve.
Posted on June 22, 2011 by Craig Becker
With much anticipation, Tennessee hospitals awaited the proposed rules from the Centers for Medicare and Medicaid Services (CMS) on how to become an accountable care organization (ACO).
The disappointment among many of the hospitals when the rules finally were released was just a great big letdown. The rules, as written, are convoluted and confusing and will make it difficult for THA members to become an ACO. Perhaps the most confounding part of the rules is ACOs would not be allowed to direct their subscribers to seek care within the ACO, and subscribers still would be free to seek care from any provider and opt out of data sharing with the ACO. It is difficult to keep tabs on cost and quality under this scenario.
While in Washington, the THA executive committee had an opportunity to meet with Nancy Anne DeParle, deputy chief of staff for policy, who told us to look to the Center of Medicare Innovation in order to accomplish what we might want to do in creating an ACO. The message to us was CMS had no choice but to write the rules the way it did because of the legislation. The Innovation Center will have more flexibility and $500 million to help hospitals create their own ACOs.
I recently was part of a CEO briefing on ACOs and, during the presentation, I noticed CEOs tapping away on their Droids and BlackBerries. I figured they were sending messages back to their CFOs to forget about becoming an ACO. Then I thought, hopefully, they are telling their staffs to just drop the O off the ACO and go for accountable care.
Let’s face it, even if healthcare reform is repealed, the hospital world, as we know it, is gone. Hospitals will have to provide accountable care using the best quality care they can, improve on patient safety, align their physicians and get their costs under control. Hospitals do not really need to have the blessing of the federal government about what is the right thing to do.
Of course, the major problem is hospitals have one foot on the dock and one in the boat. Fee-for-service is the currency of the land and capitation and bundled payments are the future. It will be a difficult few years until health care totally moves to a new payment system and the monetary rewards are in alignment with what hospitals know they need to be doing.
In the meantime, let’s not wait on the federal government to provide direction. Let’s get on with creating a more patient-centered, safe healthcare system.
Posted on May 25, 2011 by Craig Becker
There are many things I like about my job, but the best part is the membership.
Sure, I know you are all saying he has to say that, but after serving at hospital associations in three different states – New Jersey, Maine and now Tennessee – I can honestly say Tennessee hospital CEOs are the most selfless and dedicated of the bunch.
You have to look no further than the hospital assessment, which recently was approved by the state legislature. The THA board of directors and members selflessly put aside their own personal and professional bias to unanimously support the assessment so the TennCare program would not be destroyed by severe cuts that would have crippled many of the safety net hospitals.
This was no easy decision on the part of many hospitals and healthcare systems. Saving the TennCare cuts helped their competitors in many cases. It would have been easy to say no and let those high TennCare hospitals suffer on their own. It took several board meetings to iron out all the questions and concerns about the ins and out of the assessment. The discussions were frank and honest and, in the end, the vote was unanimous.
One only needs to look to our brothers and sisters to the south in Georgia to see how contentious this issue could be. There was little consensus among the members and when the smoke cleared, the hospitals found they had a true hospital tax controlled by the state. They could not get the winners to agree to help the losers, and you had some angry hospitals when all was said and done.
As we move forward into this brave new world of healthcare reform, I feel confident we will be able to weather it, mostly because Tennessee hospitals and those who lead them are willing to work together to reach common ground. This is something that gives me great comfort and hope. The continuation of Tennessee’s healthcare system depends on it.
Posted on May 3, 2011 by Craig Becker
Thirty years ago, I started as a young assistant administrator at Our Lady of Lourdes Medical Center in Camden, NJ. As you can imagine, I went in as a wide-eyed idealist about medicine and its ability to cure everything.
The first thing I did as administrator was get sick, having been exposed to every germ known to man. As I dragged myself into the cafeteria to have lunch with a pathologist who had befriended me, I asked him what doctor I should go see (even as a newbie, I realized you didn’t want to have a pathologist as your primary care physician).
He recommended Steve Vasso, an internist who became my primary care physician and mentor in all things medical. One time, when I had bad stomach problems, Steve ran all of the usual tests. I saw him coming down the hall, looking very grim.
“Give me the bad news,” I asked.
“You have the GOKs,” he said.
I, of course, think I am dead.
“You have a very bad case of the God Only Knows.”
Steve was the first one who taught me medicine was an art and not a science. He felt they only knew 20 percent of why some people got better and others didn’t. It was a shock to understand that the laws of nature could be so capricious.
Somewhere during that first year, two of my co-workers had surgery and both got serious infections. I asked Steve why it seemed we always hurt our “family” members. The eye roll told me medicine was an art, not a science, and what I should have known was it wasn’t only our “family” we hurt, but others as well.
In 2005, I learned at an Institute of Medicine (IOM) conference that there was more science to hospital-acquired conditions (HACs) and healthcare-acquired infections (HAIs) than I previously believed. No more was it about “collateral damage.” There was science involved and it wasn’t rocket science. Wash your hands, gown and follow a similar path when dealing with patient treatments. How could it be simpler?
Another truism I learned was culture eats science every day.
For too long, we have allowed culture to get in the way of providing quality and safe care for patients. Hospitals must change their culture and do it soon. Other than higher education, there is no other field I know that is so resistant to change, even if it is doing the right thing.
As healthcare leaders, it is up to us to make that culture change to one of safety first, safety all the time, safety last.
Posted on March 10, 2011 by Craig Becker
One of the joys of this job is getting to meet and know some extraordinary people. One such person for me is Sorrel King.
I got to know Sorrel through the Tennessee Center for Patient Safety, specifically when she came to speak to a group of patient safety clinicians, along with Peter Pronovost, MD, who is our chief consultant from Johns Hopkins Medical Center and instrumental in getting the center’s patient safety efforts off the ground.
Sorrel, however, has a totally different background. We, in the medical field, killed her 18-month-old daughter.
As Sorrel tells it, Josie was admitted to Johns Hopkins after falling into a hot bath at home. She was in the pediatric intensive care unit and everything was going along fine, with Josie responding to treatment. After being sent to a step-down unit, things began to go horribly wrong.
Orders were overlooked or changed, nurses were confused about treatment protocols, physicians didn’t listen to Sorrel, who pleaded that something was wrong with Josie and her care plan, and finally, a dose of methadone was administered that should have been held, snuffing out the life of an 18-month-old who had trusted, along with her mother, one of the country’s best rated hospitals to do the right thing.
This is the third time I have heard Sorrel speak and I am always caught up in her passion. She speaks of wanting to “take Johns Hopkins down one brick at a time,” and not wanting to take any money for her loss. But eventually she did and created the Josie King Foundation, which is devoted to preventing these errors from happening again. It is because of Sorrel and Josie that I am so passionate about pushing all hospitals to go for zero preventable harm to their patients.
Sitting there and listening to Sorrel this last time, I was struck by two things. One was the Tennessee Center for Patient Safety, along with our members, have made remarkable strides towards eliminating central line infections, ventilator-associated pneumonias and even MRSA. However, even if we had zero hospital-acquired infections, Josie still would be dead.
Why? Because hospital processes and cultures are so convoluted.
My second thought was we must simplify hospital systems and processes to ensure the Josie’s of the world are safe while in our care. In addition, not only do our patients deserve this, but our caregivers do, as well.
I was struck by Sorrel’s compassion when she spoke of the devastating effects Josie’s death had on her caregivers. Sorrel feels so strongly about this, she has even dedicated a part of Josie’s foundation to providing care for the caregivers who find themselves caught up in patient errors.
I was with a group of clinicians last week and a nurse who works in a hospital setting in the operating room told me she was extremely frustrated. There were so many processes, steps and silos of getting a patient to the OR that they literally lost patients. She said they had a significant backlog of elective surgeries, but no one was willing to look at the processes of getting the patient to the OR and just wanted to talk about creating more ORs.
I believe she was making the point that the current processes endanger patients, cost the system significant dollars and frustrate caregivers to the point of wanting to quit. I believe we no longer can accept this as “business as usual” or “this is just the way health care is.” If this is the attitude that is taken, we will be facing even more scrutiny from the government and, worse yet, some of us won’t survive.
To that end, the THA board of directors will spend a portion of next month’s retreat discussing, starting and funding a Center for Innovation, which will focus on process improvement and getting away from complex processes that cause harm to patients and caregivers.
I have said many times that there are three things we must do in order to survive into the future. One is to get in alignment with the physician community. They must be made an integral part of the future of our hospitals. Second, we must make sure our quality and patient safety metrics are the best they can be. The payers, government and public no longer will tolerate “that is just the way health care is.” Finally, we must get costs under control and process improvement is one major way of doing it.
If we can get all three of these working together, we can take just about anything that is thrown at us.
These will be brave times for all of us, but Sorrel, Josie and all of those patients we take care of deserve our best efforts.
Posted on March 8, 2011 by Craig Becker
What an interesting year this has been.
First, we see the passing of healthcare reform, an imperfect law for sure. But one that, for the first time, gives us hope of universal coverage. Next, we see two Tennessee congressional stalwarts and friends of hospitals, Bart Gordon and John Tanner, lost to retirement. All in all, this has been a pretty rough stretch for those us who are optimists.
Congress is in disarray, lacking in optimism and frequently failing to act like leaders of the world’s superpower. On top of that, we have had to deal with the senseless shooting of Rep. Giffords in Tucson by a madman, fueled by the lack of civility in the political world.
I know in my 30-plus years in the healthcare business, I have never seen congress as polarized as it is now, a mirror to the rest of the nation.
Yes, it has been a pretty depressing time for optimists.
Did I mention that I am an optimist? Okay, enough of the drudgery--I said I am an optimist, so here it goes.
I had the opportunity to climb Mt. Rainier with my son several years back and it was one of the hardest and craziest things I have ever done. I stopped about three quarters of the way at a spot called Disappointment Cleaver when I realized this was no place for a 55-year-old man. However, my 17-year-old son made it to the top in what became a highlight of his young life.
What I learned on Mt. Rainier and now in healthcare reform is we are the early optimists of achieving the summit. We are the ones to start this journey, even if we can’t make it to the top. It may be to others, our children, or children’s children, but healthcare reform is something that has started and won’t stop. It is up to us to make sure it doesn’t fall into a crevasse or stop at Disappointment Cleaver.
When I was the Maine hospital association CEO, I had the chance to meet some very interesting people. One of these individuals was Korean War combat surgeon Richard Hornberger, who climbed the mountain of folly that is war. Dr. Hornberger wrote a book describing his real life war experiences as caring and frustrated surgeon. The book was titled MASH and Dr. Hornberger was Hawkeye Pierce. Unfortunately, Dr. Hornberger sold the rights to the script for $500 and never benefitted from the mega millions the movie and TV rights brought. However, Dr. Hornberger didn’t dwell on not climbing to the top of the mountain of millions, satisfied knowing he had contributed to making the world a better place. In my eyes, Dr. Hornberger was an optimist.
Dr. Martin Luther King was an optimist. He believed he could end injustice to all Americans and change 200 years of racism. He didn’t live to see it happen, but he started the journey we are all still on today.
Winston Churchill was an optimist. When the Nazis were overrunning all of Europe and England looked set to fall, he carried the country with his optimism.
Astronaut Ron McNair, the second African-American to go into space aboard the ill-fated Challenger, was an optimist. At a time in South Carolina where African Americans weren’t supposed to even dream of being an astronaut, he did and he prevailed.
Don Berwick and Atul Guwande are optimists. They believe we can make our hospitals safer places at a time when many thought hospital-acquired infections and unnecessary deaths were “collateral damage” or “just the way things are.”
Let me leave you with these thoughts. Know that we have gone to the mountain, climbed and seen how good our healthcare system can be. While we may not get there, through our optimism, we have laid out the path for those who will follow us. Know we have done the right thing, we have tried and not failed, and we should take satisfaction from the journey.
We are all locked in a battle between the business of health care and the heart of health care. It is still to be determined which will win, but there is no doubt of the importance of keeping the heart in the forefront.
Another great optimist, Alan Alda, who played Hawkeye Pierce on TV, at his daughter’s graduation from medical school, concluded his remarks this way. “Let us never, ever forget that the head bone is connected to the heart bone and never, ever let them come apart. “
As an optimist, I like that.