Judul : California Health And Longevity Institute
link : California Health And Longevity Institute
California Health And Longevity Institute
i thought we'd begin with a few remarks fromeach of our panelists, since this is a discussion about moonshots for access. that we'd start with an introduction fromeach of the panelists telling us a little bit about the system and the people that theyserve. to get a lay of the land, maybe, where theysee the primary barriers to access.
California Health And Longevity Institute, so, i will start with ms. hausmann. thank you all for being here. it's really inspiring to spend time with allof you in a very common shared purpose, which
is to transform health across our globe. i have the fortune, and privilege of servingas the ceo of children's hospital colorado. children's hospitals are unique in the country. increasingly unique. there are only about thirty four free standingchildren's hospitals left. there are many large systems that take care of children thatreally do all work together. but one of the things that we have discoveredin colorado is we are serving kids from all 50 states. we are serving kids from twenty seven countries.
increasingly, we are becoming the destinationfor some of the most complicated medically complex children. we're the number one provider for the departmentof defense right now and military families who have children with medical complexities. as you begin to look at that, you begin toreally change the nature of some of the higher end care that you're providing when childrenare traveling across the globe, across the country for care. that is absolutely how we think about accessfor some of our more acute services, which is a real key part of how we want to thinkabout transformation.
but also, we serve seven states that surroundus, that don't have a children's hospital for some of the lower end acuity work. so we really, in our organization, think aboutthis across what this means for children. whether it's some of the more minor, lesscomplex things that we would love to get out of a health system as we've traditionallyknown it, and figure out how to get it into homes, get it into schools, and we can talkmore about that. where it's much more right care, right time,right place, right provider, right experience. so, that's a really big part of who we are. not just serving colorado, but seven statesthat need that, in addition to the super complicated
care that's needed in some of those higherend specialties. well, some of the same themes. i'd like to first thank startup health fororganizing this and it's a pleasure being on the panel with both of you. we're about a seven and a half billion dollartop line revenue organization. about thirty percent of our patients are medicaid,thirty percent are medicare, and forty percent are commercially insured. we view, still, after this current election,that the triple aim has got to be our goal. that's access, quality, and cost.
we feel very strongly that access is a keyissue and if we’re going to talk about inequality in the country, that access becomes a criticalpiece of information. there are a number of parallels between underservedurban populations that we serve in brooklyn, queens, manhattan, and underserved rural populations. there our broadband access issues, there areaccess to primary care issues, there's access to urgent care. there are a range of issues that we feel weneed to extend beyond the four walls of the hospital and what we do. so, we are diligently trying to apply expansionof primary care, expansion of school-based
clinics, the expansion of our physical footprint. but that's got to be conjoined with an expansionof the digital footprint. otherwise, i don't think the access problemscan be solved. well, thank you very much for time to talkto you for a little bit. let me just speak to you a little bit aboutaccess. access in washington means insurance. access when you're sick, means actually beingable to see a provider. so, we have radically changed our approachto access. we feel that access ought to be anytime, anywhere.
we started with this a number of years ago. we now have emergency rooms which see peoplewith an average of eleven minutes waiting time. then we became concerned when patients neededto be seen and couldn't, so we went to same day appointments. now, everybody who calls up, we say wouldyou like to be seen today? we saw 1.3 million same day appointments lastyear and ninety eight percent of the people who asked for one got one. we've also gone to virtual visits and offerpeople to get it on their cell phones, skype,
however. you can click in an appointment, you can walkin an appointment with an increasing number of facilities where you can simply walk inwith no appointment. we think that you ought to be able to seepeople anytime that you want to see people. quite frankly, the same day appointment issuestarted from a single case. of a patient to wanted to make an appointmentwith urology and he was given an appointment in urology in two weeks. it turned out he was in acute urinary retention. our lesson from that was that you have toask the patient if they want to be seen or
not. and so our objective is to make access universallyavailable to our patients. so, each of you talked about the ability toactually get to see somebody. in your case, you’re covering multiple states. you talked about the availability of providers. you talked about, can somebody get in to seea clinician in a timely manner. just to kind of narrow it down to one sliver,i'd be interested in ways in which you might be trying to apply technology to address someof those accessibility issues. we'll set aside just for just a moment, setaside the question of whether or not it's
affordable. we’ll get to that next. but, in terms of just being able to get tothe person that has the knowledge that you need. let me start, and i’ll give you one experimentthat we’ve had. we’ve seen emergency department visits growby about seven to ten percent per year, even after the passage of the affordable care act. it was supposed to go down, have gone up. time to provider was going up.
we made a decision that we were going to havevirtual visits in our emergency room. kiosk visits. so we were able to do, i think we’ve doneover a thousand such visits. it lowers the total amount of time in theemergency room from about two hours to about thirty minutes. we can cover two or three emergency roomssimultaneously and we take people who have grade four or five conditions. those conditions that are not deemed to bein immediate need for acute physical care. so it’s that type of combination of thingsthat i think can start to deal with the issues
of access, and the emergency setting is oneexample.yeah, and i think the other thing is, it’s similar, we’ve gone to what'scalled split flow. so, if you’ve come in with a sprained ankle,you don’t have to take your clothes off, get on a stretcher, and go into a room. you’re put to be seen as an outpatient andthat leaves the opportunity to move people through faster and we've used a lot of physicianextenders. we have in our system about 1500 nurse cliniciansand pa’s across our entire system and there's going to be more and more of that all thetime. one of the things we're doing, there's a reallyacute shortage of mental health providers
in the pediatric space. so, we're using a lot of the telehealth technologiesto try to connect to emergency departments across the region so that they have immediateaccess to pediatric mental health providers, either psychologists or psychiatrists, sothat we can help them do a triage, and assessment in their home community ed, manage that situationif appropriate, or do the appropriate referral. but parents are really scared out there andproviders are nervous, and so that has been a really important telehealth utilizationof a subspecialty that's in really rare demand.that's a terrific example and we do the same thing. i think you'd be surprised to know there areless than 10,000 child and adolescent psychiatrists
in the country. not in the state of california, in the country. so, this is an acute need and any of the psychiatriststhat do child & adolescent psychiatry are seeing outpatient. so, it's a terrific example. and telepsychiatry is but one type of on-demandservice that i think is truly beneficial and truly necessary. you know, another interesting thing is theuse of new technology around stroke. we are now increasingly trying to take thecare to the patient and in fact we've put
together a cat scanner within an ambulanceand so when someone calls in 911 to say they have symptoms of a stroke, we dispatch thisambulance. they do the cat scan in the driveway. they can start thrombolytic therapy rightthere in the driveway and we've had some amazing saves. so, they do the cat scan, it's read distantlyback at the main campus, and then they make the decision as to whether they're going togo ahead with it. so, increasingly we're trying to move thetechnology to the patients. whether it's monitoring them for chronic disease,virtually, or whether it’s taking the advance
technology to them, or whether it’s havinghome visits by physicians to begin to look at people with chronic disease and keep themout of the hospital.so, we've been talking a little bit about inside of the hospital. i'm interested in the ways in which you maybe trying to increase access outside of the hospital. you all operate hospitals, but increasinglyhospitals operate outside of the four walls of acute care. so, where do you see opportunities to increaseaccess outside of the acute care setting? well, we haven't mentioned the four letterword that jumps to everybody's mind which
is cost. so, part of this discussion around virtualvisits, and for certainly all of you who are entrepreneurs is, how can we do things better,faster, and cheaper? what are the solution sets that will improveproductivity in an industry that can deliver terrific results but has got relatively lowproductivity? the same number of nurses are taking careof the patients in terms of ratio that they were 10 years ago or 15 years ago. when you get to the outpatient setting andyou're trying to provide even more preventive care, the ability to prevent somebody fromcoming into the hospital, these are very expensive
models of care. we've all done them and you can show prettydramatic results in reducing emergency room visits, reducing emergency visits for childhoodasthma, and so on and so forth. but they are very costly. because the models are not meant to be reimbursedat a reasonable rate. and so, you have to rely on things that canreally extend you and leverage your personnel. one of the things we're looking at, and it'sjust on the beginning journey, is partnerships with schools. children spend a large portion of their dayin the school setting.
the school setting is becoming overwhelmedwith behavioral issues in addition to the educational demands. and so, we've adopted a couple of schoolsin our local neighborhood to start some very important pilot work to try to figure outhow that becomes a new care setting for us. whether we're actually bringing our personnelinto the school setting in a different way and redefining the old school nurse as weall remember. or, how we leverage technology to do thatand how we take all the rich inputs about that child. the social dimensions, behavioral dimensions,as well as the physical dimensions of that
child into a more comprehensive look at thehealth and well-being of that child and capture that information in a more integrated, connectedway so that we see a whole picture of a child. and then we can target strategies with notjust the schools, but with parents in a different way. because parents also relate to the schooldifferently than they relate to the healthcare system. so, that's on our journey coming up. well, as steve points out, one of the thingswe have to talk about is cost. and there's really only two ways we're goingto reduce costs.
we can have a more efficient healthcare deliverysystem for the sick, or we can keep people well. and there has probably not been enough emphasison keeping people well. one of the things, we've gone to the schoolsthe same way my colleagues have, but we've gone one step further and we've found thatwe can reach an awful lot of people through the churches. we've put together a major program with thechurch's, in terms of weight reduction. across all cleveland and we've had enormoussuccess with that, reaching out across this entire community.
which is really been very gratifying. when we talk about access and the ways inwhich the cost of care can limit access. there are a couple things that for me cometo mind. when is, as you talked about, is the costof the system itself. the other is, just the degree to which thepeople who seek and receive care and pay for it. having information they needed to make thedecisions, like, the word escaped me. to make, sort of like, to essentially, comparisonshop. like i recently went to the dermatologist.
right? so, i went and tried to find a little information. both, on what it would cost, and the relativequality of the dermatologist. it's not easy. so, let's start with ways in which your organizationsare trying to reduce your own costs. the cost of delivery. i'd be interested in whether or not you'reusing new data that you’re collecting through various sources to try to identify what’sefficient, who are the most efficient providers, any other internal engineering that you’redoing to try to address your operational costs.
would you like to start? yeah, i think that we recognize that on an8 billion dollar organization we probably need to take out about 1.5 billion dollarsworth of cost over a five-year period of time. so far and about two and a half years, we'vetaken out 700 million dollars worth of our cost and we've done it every way that youcan imagine. but ultimately, it's going to require thatwe change the way we deliver care. we've done several things. virtual visits is one of them, which clearlyhas an opportunity to do that. one of the other ones we've done is groupvisits where 12 people with the same diagnosis
i seen at once. if you are diabetic, you get your diabeticinstructions as a group. interestingly, people like it. it's like group therapy. they realize they're not the only ones thatof got this problem and they share the experienced and it's really very satisfying for them andobviously efficient. but ultimately, we have got to change howwe deliver care, and one of the ways we are going to do it is going to happen more andmore, by having more and more physicians assistants and pas, and have everybody practicing atthe top of their license.
i would say that this is something we've beendoing now for at least 40 years and have found it's tremendously satisfying for the patients,they get better care, and certainly it elevates the position so that they're not doing workthat could be better done by somebody else. and this is going to go on across the entiresystem, because we have a shortage of almost 100,000 doctors across the country and theonly way we're going to supplement those is by additional individuals, technicians, etc,who are going to pick up the pace and fill in those things. major different ways. but also, you have to look at everything.
there’s no sacred cows. we closed services, we consolidated services. one of the things that i would say is, ultimately,healthcare is, currently in the united states, a cottage industry and like every other industryin the united states it has to consolidate. i hope that the new administration talks tothe justice department a little bit about allowing us to do that. because clearly, that is another way we candrive the efficiency of the healthcare system. i agree totally with dr. cosgrove. let me take it from a somewhat different perspective.
20% of the patients are driving 80% of thecost so, point number one is, you gotta deal with the very high-cost patients and thatrequires a lot of coordinated care. we've got to put, as a country and individually,much more resource into mental health because if you add a mental health substance comorbidityto any diagnosis it doubles or triples the cost of caring for that patient. so, if you want to ring cost out of the system,deal with the 20%, deal a lot with some of the mental health issues. the other thing we're going to have to recognizein taking cost out, is we have to deal with vulnerable populations.
believe it or not, the urban and rural vulnerablepopulations are not that different in terms of what they need. finally, what i would suggest is that highquality takes cost out of the system. it avoids redundancy, you avoid complications. to follow up on dr. cosgrove’s point, ithink that consolidation, appropriate with competition, but also developing standardsof care, which he has certainly been a leader in,. you both have, becomes critically importantin terms of bringing cost out of the system. reducing variations, standardizing care, requiresa degree of industry consolidation that we’ve
not yet had. yeah, i won't repeat, because those are criticalthings that i think a lot of healthcare leaders are really needing to do to continue to focuson costs. in pediatrics, 6% of the kids drive 40% ofthe cost. so, it's a sort of exacerbated issue, we havea target population we know we need to focus on and we can really laser focus creativeinnovative strategies around managing the care of those vulnerable populations and havea really big impact when we do that. you started down a path that i just want topick up, is transparency in data systems and i think these are two really important thingswe need to be thinking about in the health
industry. transparency is essential. we cannot improve ourselves if we're not honestabout how we're performing. you cannot make good choices as a consumerif you don't know what is truly the performance of the choices that you're making, eitherbetween providers or health systems and the experience. and so i think we all in the industry haveto just keep going towards bringing transparency, both in quality outcomes and costs data. and then data systems.
i don't know about you, but right now, wespend a lot of money in data, but we're not yielding a benefit. it's not dropping cost. it's actually increasing cost. and so, i think how we work with smart datasystems, where they’re not just repositories, but they’re actually serving us in trueanalytics and informatics that we can act on, i think, is something the healthcare industryis still in need of some innovation on. but, i’d like your thoughts. let me just add on to that.
we started a number of years ago a companycalled explorys. and explorys collected 50 million patientrecords and recently was sold to ibm as grist for watson. and ibm is building on our campus a watsonhealthcare building that we think is going to be essential. as you look at it, the explosion and knowledgethat's going on in healthcare is something that's absolutely overwhelming. by 2020, the total amount of knowledge inhealthcare will double every 73 days. right now there are 800,000 journal articlespublished a year.
there 5600 journals publishing those. no one is going to be able to keep up withthose. so we are actively engaging watson to beginto deal with this explosion and knowledge that we're having, not just in terms of miningit, but also helping physicians make good decisions and diagnosis, particularly whenyou begin to have genomics bringing massive amounts of information that we're going tohave to deal with as part of both the diagnosis and the treatment of our patients. yeah, i agree with that completely. i think artificial intelligence and machinelearning is going to be critical as we move
forward. for those of you who read robert gordon'sbook on productivity, we have hit a productivity slowdown in this country and healthcare isa big part of the gdp and our productivity in healthcare is not what it needs to be. to jena's point, the productivity associatedwith information technology has not yielded promise at this point. in fact, currently information technology,especially the electronic records, make seller clinicians less productive. not more productive.
there may be other benefits but productivityis not one of them. so one of the key things i think for us isto start to accelerate productivity enhancements. ai may do that, machine learning may do that. enhancements to the way that we care for patients. we still have 60, 70 year old ways of caringfor patients, in terms of rounding, in terms of communication, in terms of handoffs. so there is a wealth of opportunity overlaidon top of the ehr for companies to make a big difference in terms of the productivityof the healthcare space. could i just have one more plug here?
and this is not going to be very sexy or hi-tech. but there are two things that count for theenormous amounts of cost in health care. that's smoking and obesity. obesity right now counts for 10% of the healthcare costs in the united states and smoking is the number one preventable cause of cancer. we still have 22% of the people in the unitedstates smoking and it's not going down. we made a fairly bold move. we stopped hiring smokers. the reason we stopped hiring smokers is becausewe felt that it was important to send a message
about what a healthcare organization stoodfor. sort of an amusing sidelight of this, everybodywas really concerned when we went into this, because the highest instance of smoking ina hospital is by respiratory therapists. just sayin. we were worried that we weren't going to beable to have respiratory therapists anymore. well, turns out that there are a bunch ofrespiratory therapists that don't like smoking. so we've been okay. i do want to come back to this point abouttransparency. could each of you describe what it is thatyou do, your organizations do, to put forward
cost and quality information to individualconsumers? i don't know if it's through the contracts,contracting with health plans that put together their own accessible information for healthplan members or if that's information that's provided to employers or if it's informationthat's on your website? i'm just kind of interested in where you'reat. we'll start there. i think it's much easier to talk about qualitythen it is about cost. what we did with quality is we started a decadeago and asked each one of our departments to put an outcomes book together.
the outcomes book, essentially, gives youthe good, the bad, and the ugly of what we've done last year. we did that for two reasons. the first reason was, every time we lookedat it we find something that we could do better. it's like looking in the mirror. and it was good for us in improving our quality. the second reason is, we are a community resourceand we owe it to the community to tell us what our quality is and so we've been verytransparent. you can get it in a paperback form, you canget it at the website, but it's all out there
and upgraded on an annual basis. to start with, some of it was not very sophisticated. but each year it gets a little more sophisticatedas we go forward with this. the cost is really difficult. we have over a hundred contracts with differentproviders and trying to figure out what we are charging for a colonoscopy in one placeor another with one contractor or another gets to be enormously complicated. there are now companies that have come alongthat are offering this more and more. pushing transparency.
castlight was one of the leaders in this. but it is not yet generally available acrossthe country. yeah. i would also like to point out. and this is just the conundrum that, as acountry, we find ourselves in, is that medicare and medicaid do not pay costs. so you're dealing with let's say $0.70, $0.75on the dollar for medicare and medicaid and that's got to be offset by a dollar 20 ora dollar 30 on commercial contract. and so one of the issues we're going to faceis if you just take your medicare and medicaid
patients it's difficult to make it. the safety net hospitals in the country aregoing to have issues. that’s part of the issue that you're seeingin inner-city hospitals, certainly in my city, and it is a big conundrum. so, to the earlier point that was made. you have 70 + million people in the countryon medicaid. medicaid policy becomes extremely importantin terms of how the country progresses. if medicaid gets cut back, that will put afurther cost burden on those patients that so, this issue of transparency around whatprice are you paying, a: depends on the contracts,
but b: it also depends on what governmentpolicy is for medicare and medicaid reimbursement. if we are convinced as a country that we arespending too much and not getting enough for it, then the issue really has to become exactlyhow are we going to move forward to improve the quality of care and the quality of theoutcomes. almost teed me up for a soapbox on medicaid,but i won’t go there. about half of most children's hospital’srevenue comes from medicaid as a source, so we are tracking that with extreme interestand hopefully influence in that voice. i’ll just give an example about preventableharm. hospitals are not always the safest placeto be in.
there are many bad outcomes that can happenwith things that could be prevented, so we took very, very seriously, 6 years ago, butwe have been reducing the number of children that have been harmed. and we don't just, we haven't just reducedit by over 50%, we put faces and names, not just statistics. we publicize it all over our organizationand on our website and every family who has a child into our organization, we talked tothem about what could happen and how we need that parent to be part of the care team tohelp us prevent unintentional harm while their child is in our care.
and that was a very difficult decision tomake because the lawyers hated it, the risk managers hated it. but we had to go there. we had to be bold and say no, and order todrive to 0 preventable harm we have to be honest about how much harm is happening inour organization and talk about that, not just with ourselves, but truly with our patientsand families. i’m going to open it up for questions. oh. we are going to open it up for questions now.
i apologize. i was looking at the wrong spot for the timing. so we got mic runners, if anyone has any questionsfor our panel. thank you for all the things that you share. very interesting. you mentioned that you're offering new channelsfor people to access healthcare, as the first action is to facilitate this access. but, in my opinion, it leads to another challenge,which is how do you help people make the right decision on what is the right channel to accesshealthcare so that it can be provided in a
cost efficient way? you mentioned same day appointments, you mentionedteleconsultations, these kinds of things, so, every time people have more options, buthow do we support them to make the right decisions so that they make the most efficient decisionon how to access healthcare? i think increasingly you have to include thepatient in the discussion. and that requires giving them the optionsand having a meaningful discussion with a patient upfront about what the options are. whether you're going to, coming to the endof life issues. that is a very important issue that we haven'ttouched on which is the end of life and the
discussions that have to go on with families,providers, patients, and there's another issue about, a very difficult one, about the economics,the social aspects of it, the emotional aspects of it, all are incredibly important and alsorequire very straightforward discussions. there is guilt in everybody who deals withthe end of life and you have to put that out there and have an open discussion about it. i think it's, that is one of the tough decisionsthat you have to make, probably the toughest. but transparency helps it, and candor helpsit enormously.thank you. i've been a healthcare provider most of mycareer and obviously it would be very hard to find a healthcare provider like dr. cosgrovewho would argue against reducing costs and
improving quality. but in terms of reducing costs, one of thefactors that i know you all know about, but you may want to comment to the audience relatesto how you reward institutions, health care providers, and healthcare systems in orderto allow them to reduce costs, improve quality, given the perverse, fee-for-service, production-basedincentives that even the government puts in, in terms of how we’re reimbursed. for example, it’s sad to see now in medicarefor example, that primary care physicians probably are going to opt out of medicareat the expense of our seniors and disadvantaged people, because of the way the system works.
as thought leaders i was wondering how youdeal with this perverse way where we are reimbursed to take care of our patients in terms of thisfee-for-service model. as an institution or a provider.the questionwas with fee-for-service having perverse incentives to see more and more people, how do we asproviders look at it? because in part, we depend on revenues fromthe volumes that come in to us. i’ve sort of looked at it, as an institutionwe’ve looked at it, that we’re a not for profit institute that exists for the publicgood. one of the public goods is to reduce the costof health care, therefore, we are going to reduce utilization.
we are going to take unnecessary utilizationout of the system as much as we can. i believe that with organizations that areup here, that the remaining utilization will come to places like us that people can trustand rely on. and if they can't trust and rely on us, theywill go somewhere else. to the point about transparency, you haveto show what you can do, and so what the outcomes are. i admit that there are perverse incentivesthrough fee-for-service, there's no system that's been created that doesn't have perverseincentives associated with it, if you take it to a certain extreme.
but i think that is health care providers,we've got to help the country in its efforts to reduce cost and that means taking out utilization. let me just say one more word about that. first of all the way we're organized, we allare salaried. there's no financial incentives for us. just a straight salary. we have one year contracts and annual provisionalreviews. i've had 42 one-year contracts. i'm looking for 43.
i wish we had more time but that's it. thank you very much for the excellent questionsand thanks to our panelists.
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