“Let us not forget these fundamental resources of our profession—the power of our hands, our voices, and our rational thought—for these are free but priceless, so if value is the ratio of cost to worth, theirs is infinite.”
An article in Pacific Standard magazine reports:
”Our C-Section Rate Won’t Budge—Is It Because We Don’t Trust Women’s Hormones?
”An unprecedented new report looking at the biochemical mechanisms linked to birth and breastfeeding suggests that over-treatment in the delivery room is having lasting, harmful effects on both mothers and children.”
See the news below on the federal funding cliff for community health centers. Below it is an article on Cambridge Management Group’s successful engagement at a Federally Qualified Health Center in Massachusetts that had been in crisis.
From the National Association of Community Health Centers Web site:
”Health and Human Services (HHS) Secretary Sylvia Mathews Burwell on Feb. 26 warned a House panel that unless addressed this year by Congress, the health center funding cliff will lead to more than 7 million patients losing access to care and 40,000 jobs lost with over 2,000 health center site closures.”
”Burwell’s testimony before the Subcommittee on Health focused on 2016 HHS Budget Request, which requests funding for, among other programs, Community Health Centers and the National Health Service Corps (NHSC) – two key healthcare programs that ensure people in underserved communities have life-saving primary and preventive care when and where they need it.”
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Here’s the article on Cambridge Management Group’s successful work to help turn around a large Federally Qualified Health Center — Community Health Connections, based in Fitchburg, Mass:
CMG helps turn around CHC
By Yvonne C. Acquafredda, MBA, and Lillian J. LeBlanc, MBA
Today’s healthcare organizations face increased pressure to deliver high-quality and cost-effective care. A key element in enabling them to do this is creating work environments that encourage teamwork on all levels, from board members to all employees.
The Great Place to Work Institute, which studies organizations around the globe, notes the importance of collaboration in the workplace. Great enterprises of all sizes structure their operations to encourage employee cooperation to achieve their organizations’ goals.
Fitchburg, Mass.-based Community Health Connections (CHC), a system of outpatient clinics providing medical, dental and behavioral-health services to thousands of mostly low-income residents in 20 communities, achieved an operational turnaround through a new focus on cross-functional cooperation and clearer and more consistent management.
This was accomplished in partnership with the healthcare-sector consultancy Cambridge Management Group (CMG) and the executive-search firm ZurickDavis (ZD).
CHC is a Federally Qualified Health Center (FQHC). With changing demographics and healthcare reform, such institutions play an increasingly important role in the U.S. healthcare sector. CHC’s experience has lessons for a wide range of healthcare and other organizations across America.
Established just 10 years ago, CHC grew rapidly as it responded to urgent needs to provide primary care in north-central Massachusetts. As patient volume increased, clinicians and administrators worked diligently to meet the demand. But CHC’s organizational structure and culture acted as barriers to examining and improving business processes even as clinical demands surged. By 2013, CHC found itself near receivership. As CHC board member Gregg Buckman put it, “the financial issues were staggering.” In addition, employee morale fell to an all-time low.
Would CHC collapse in the face of the demands being put on it?
Cambridge Management Group Transforms the Organization
Fortunately, CHC’s forward-thinking board recognized the broad range of issues facing the organization and contacted CMG to find ways to stop the losses and then stabilize, focus and grow the organization.
Crucial parts of the engagement that followed were to emphasize collaboration at all levels and to clarify the institution’s needs and goals.
CMG typically operates as a partner of management, providing guidance, expertise and best practices learned over the company’s three decades. As Lia Spiliotes, a CMG partner and senior adviser, explained: “We don’t do what you do; we help you do what you do better.”
However, due to the depth of the challenges at CHC, the board and CMG agreed that interim leadership was needed. Thus Ms. Spiliotes became interim CEO and her CMG colleague Kevin Ward interim CFO.
CMG brought its corporate philosophy of servant leadership to CHC, emphasizing executive approachability and openness without all the traditional boundaries of organizational hierarchy. For example, before CMG’s arrival, CHC executive offices were in an area of CHC headquarters removed from most employees and patients. The interim leadership team established its base in a former gift shop called “The Fishbowl,” in the middle of CHC’s main building. All employees were welcomed to come by.
Another example of this approach was that Ms. Spiliotes invited CHC billing people to meet with the interim leadership team, to give the latter perspective on CHC’s billing processes and present ideas for improvement.
In the initial meetings, all employees were quiet, seemingly afraid to speak up. But over time, as staffers observed, and regularly interacted with, the interim leaders, candid discussion helped to reveal several core operational challenges. One, identified by the billing team, was a communication breakdown between the clinical and billing departments, resulting in many claims being denied. Absent cross-functional teams, the communication changes needed to capture lost revenue would never have been identified.
Over the months of CMG’s leadership, through regular communication and increased collaboration, employees identified many administrative, financial and clinical concerns. Workable solutions were designed in response as the newly collaborative process led employees to feel more empowered, energized and invested in CHC’s success.
ZurickDavis Leverages Collaboration for the CEO Search
As a new culture took hold, the CHC board turned considerable attention to recruiting a long-term leadership team. Sustaining CHC’s turnaround would require leaders with the same understanding of servant leadership that CMG brought, able to relate to employees at all levels and willing to invest the skills, time and energy needed to support organization-wide collaboration to achieve operational success.
So CHC’s board reached out to a trusted business partner, the executive-search firm ZurickDavis. CMG and ZD had been familiar with each other’s work for years.
In the spirit of collaboration, so much a hallmark of the CMG-ZD engagement, the latter’s staff invested considerable time to understand the needs of the organization, including requirements for new leadership. ZD went beyond standard job descriptions and the conventional executive-search process; it approached the engagement with few assumptions. It intensely interviewed several CHC board members and the interim leadership team, letting ZD come to fully understand the organization’s evolution and needs.
Armed with this information, ZD developed a profile of the ideal CEO to maintain CHC’s momentum. Through careful listening to the stakeholders, ZD recognized that certain qualities of character would be even more important than very job-specific skills. The new leader must be someone “committed to serve, unpretentious and genuine,” ZD found. He or she should possess a “naturally respectful, consultative, collaborative and accessible leadership style,” but also show “a willingness to lead decisively, to energize and inspire.”
ZD was a full partner throughout the process. According to ZurickDavis’s Ellen Mahoney, who worked closely in the search, steady openness and collaboration informed the whole process. “Everyone was transparent. We were a part of all meetings and fully utilized as a resource.”
Jeff Zegas, ZD’s chief executive officer, said that this level of cooperation and candor, especially in hiring a new leader, is crucial to any organization wishing to strengthen its culture and thus achieve and maintain operational success over the long term.
Building a Collaborative Organization: The ROI
Although CHC’s transformation is still a work in progress, outcomes show the positive impact of the CMG-ZD engagement. CHC achieved a positive fiscal 2013 cash flow (before depreciation) of nearly $190,000, compared with a negative $1.2 million for fiscal 2011. Eligibility denials involving erroneously entered insurance claims were reduced by almost 65%. And the organization enjoyed unprecedented public support for its $20 million project to build a new Fitchburg Family Health Center.
However, much still remains to be done. CHC’s board chair, Mary Giannetti, offers this advice to other organizations that need to effect profound change. “It takes commitment at all levels, but you don’t have to do it alone. Call in the experts and place trust in those you hire.” CMG co-founder Bob Harrington sums up the process at CHC: “Give employees some autonomy and expectation of accountability and you will motivate them to succeed.”
Yvonne Acquafredda has provided broad-based marketing and communications support to several companies in consumer services and healthcare. She has extensive experience in multi-site organizations. Ms. Acquafredda has a bachelor of science degree in communications from the University of Miami, a master of business administration degree from Northeastern University and a certificate in digital marketing from Rutgers University.
Lillian LeBlanc has more than 30 years of experience in the healthcare industry, assisting organizations with cultural transformation and boosting organizational effectiveness. She has worked with healthcare systems in Boston, Maine and South Florida. Ms LeBlanc holds a bachelor of science degree in economics, summa cum laude, from Boston State College and a master of business administration degree from the University of Massachusetts. She is a guest blogger for the Great Place to Work Institute, which produces Fortune’s annual list of 100 Best Places to Work For in America.
Yet again, Massachusetts is a pacesetter for health-insurance reform.
The Boston Globe reports that Blue Cross Blue Shield of Massachusetts ”will vastly expand its system that pays doctors based on how well they care for patients {aka fee for value}— not just for the number they see and volume of services they provide {aka fee for service}. The move will extend the quality-based system to more than 1 million health plan members, making it the biggest initiative of its kind in the state and probably the country.”
”The move by Blue Cross, which controls 40 percent of the state’s commercial insurance market, should hasten the decline of the way American doctors have been paid for decades, analysts said”.
The Globe elaborated: “Blue Cross will essentially pay doctors a set amount to care for their patients but payments will ultimately be tied to how well doctors and hospitals score on a variety of quality measures.
”For consumers, the change will mean more coordinated care and management, such as follow-up visits by home aides after surgery and phone calls to make sure patients take their medicine.”
By PHIL GALEWITZ, for Kaiser Health News
Hospitals that treat many poor and uninsured patients were expected to face tough financial times in states that did not expand Medicaid under the federal law known as Obamacare.
That’s because they would get less Medicare and Medicaid funding under the Affordable Care Act, while still having to provide high levels of charity care.
But in some of the largest states that did not expand Medicaid, many safety-net hospitals fared pretty well last year — even better than in 2013 in many cases, according to their financial documents. KHN looked at the performance of about a dozen such hospitals in Florida, Texas, Georgia, Tennessee, South Carolina, Virginia and Kansas, which released their 2014 financial results.
An improving economy was the single, biggest reason shared by all of the strongly performing hospitals because it helped reduce the number of patients who couldn’t pay their bills and increased local property and sales tax revenues earmarked for publicly supported hospitals.
Another factor for some hospitals was the increase in insured patients who bought coverage through the health law’s insurance exchanges. For instance, Fort Lauderdale, Fla.-based Broward Health saw a 30 percent drop in charity care, which officials attributed to seeing more insured patients.
Still, the biggest fiscal challenges lie just ahead — with significant Medicaid funding cuts starting late next year under the Affordable Care Act. The health law’s drafters anticipated the number of uninsured Americans to decrease dramatically, in part because they expected a nationwide expansion of Medicaid.
Therefore, beginning in October, 2016, the law calls for cuts to special Medicaid funding for hospitals that typically see a disproportionate share of the poor. In addition, other Medicaid funding that supports indigent care in certain states (and that predates the 2010 health law) is slated to expire in Florida in June and in Texas, next year.
“We are still very early in the Affordable Care Act, and one year does not make a trend,” cautioned Daniel Steingart, an analyst with Moody’s Investors Service. “Just because they got though this period, does not mean they do not have more financial pain to come.”
So-called safety-net hospitals, many of which are supported by local or county taxpayers, often struggle financially because they see a high proportion of patients that are either uninsured or enrolled in Medicaid, the state-federal program that pays less money than Medicare or private insurers. The hospitals face added pressure from providing high-cost and traditionally money-losing services such as trauma and burn care. They also have the expense of training doctors.
Nonprofit hospitals need to make enough money to buy new equipment, expand programs and meet rising labor costs. The average nonprofit hospital makes about a 3 percent profit margin, Steingart said.
In the past decade, two of the nation’s largest public safety-net hospitals — Grady Memorial Hospital, in Atlanta and Jackson Memorial Health System, in Miami — were on the verge of financial collapse but recovered after major management changes and increased public support.
Last year, the county-owned Jackson finished its second consecutive year with about a $51 million surplus on about $1 billion in revenue, in part as a result of increased county sales-tax revenue going to the health system and tighter expense management. Jackson’s operations are supported by a sales tax in Miami-Dade County.
Grady’s profit increased to nearly $30 million through November last year, up from $17 million for the same period in 2013.
Several other safety net facilities in states that did not expand Medicaid had profits in 2014, according to financial reports, including:
— Broward Health, which runs four hospitals, saw $69 million in profit in the 2014 fiscal year that ended June 30, compared to $59 million a year earlier, on about $1 billion in revenue. That included support from local taxpayers.
— Orlando Health, a six-hospital system in central Florida, saw its profit grow to $161 million in the fiscal year that ended in September, up from $32 million the year before, on about $2 billion in revenue. Its vice president of finance, Paul Goldstein, cited the improving economy, an increase in the number of privately insured patients and the financial performance of recently purchased doctors’ groups.
— Tampa General posted a $49 million profit last year, up from $31 million the year before, on $1 billion in operating revenue. Its operating margin was 4.5 percent.
— Chattanooga, Tenn.-based Erlanger Health posted a $20 million profit for the six months that ended Dec. 31, on revenue of $336 million, after factoring in local tax support, compared to losing $1.5 million in the same period a year earlier.
— Greenville Health System, in South Carolina, made a $63 million profit in the fiscal year that ended Sept. 30, down slightly from $80 million the prior year. The system had about $1.8 billion in revenues.
“Safety nets are doing everything they can to hang in there,” said Beth Feldpush, senior vice president at America’s Essential Hospitals, which represents about 250 safety-net hospitals.
Twenty-eight states have expanded Medicaid under the health law since the Supreme Court ruled the provision optional in 2012. Medicaid enrollment has increased nationally by almost 11 million since October 2013. Most of the drop in uninsured nationally is attributed to people gaining Medicaid coverage.
Not all safety-net hospitals did well last year. County-run Harris Health System, in Houston, is facing a $14 million budget shortfall and recently announced plans to lay off 108 workers. Officials blame Texas’ decision not to expand Medicaid and decreased payments from other federal programs. Nearly two-thirds of Harris’ patients are uninsured— a far higher percentage than at most safety-net hospitals.
Chief Financial Officer Michael Norby said the hospital has seen a nearly 2 percentage point increase in privately insured patients as a result of the health law. Even so, only 3 percent of its patients are privately insured. “We are significantly challenged as we go forward,” Norby said.
Parkland Health and Hospital System, which is supported by Dallas County property taxes, managed to finish in the black, but saw its profits decline from $43.4 million in 2013 to $1.4 million in 2014.
Meanwhile, safety-net hospitals in Florida fear what will happen after June 30 when $2 billion in federal funding expires under an agreement between the state and the federal government. Under such agreements, the federal government supplies billions of dollars in special Medicaid dollars to certain states including Florida, Texas and California to support hospitals with large number of Medicaid and uninsured patients.
“Without those dollars we have an unsound system,” said Tony Carvalho, president of the the Safety Net Hospital Alliance of Florida.
While Miami-based Jackson Health is financially healthy now, Chief Financial Officer Mark Knight worries about the end of that federal waiver funding in June, which contributed $160 million to his budget this year. “We could not continue to serve and maintain current capacity … without that money,” he said.
In 2014, Florida safety-net hospitals also benefited from a strong tourist season and lower unemployment rates, Carvalho said.
The improved economy also helped many safety-net hospitals that are supported through local property and sales taxes, such as Broward Health and Jackson Memorial, said David Gruber, managing director of research at Alvarez & Marsal consulting firm.
A recent report by the firm predicted the nonprofits would face major financial threats as a result of health law funding cuts, particularly in states that do not expand Medicaid. “Safety-net hospitals are now operating in the untenable crosshairs of economic distress and healthcare reform,” the report said.
Greenville Health has kept in the black partly by finding ways to trim charity care costs, said Chief Financial Officer Terri Newsom. The South Carolina hospital has hired case managers to oversee care to some of the uninsured patients who show up regularly at its emergency department. It also launched a program to divert ambulances with patients who do not have medical emergencies to urgent care centers.
Though the hospital worked to get people signed up for Obamacare plans, it only saw a 1 percent drop in uninsured numbers last year. Nonetheless, administrators say the health system is in good shape. “We are in stable health and making the right investments,” Newsom said.
And indeed many more of America’s healthcare and law- enforcement system challenges could be better addressed if there were more understanding of the huge role that mental and behavioral health play in crime and in more overtly “physical-health” matters.
And why don’t more of the mentally ill take their medication?
Because they’re mentally ill.
Top 10 measures for palliative care published online in the Journal of Pain and Symptom Management, courtesy of Hospitals & Health Systems:
1. Palliative care and hospice patients receive a comprehensive assessment (physical, psychological, social, spiritual and functional) soon after admission.
2. Seriously ill palliative care and hospice patients are screened for pain, shortness of breath, nausea and constipation during the admission visit.
3. Seriously ill palliative care and hospice patients who screen positive for at least moderate pain receive treatment (medication or other) within 24 hours.
4. Patients with advanced or life-threatening illness are screened for shortness of breath and, if positive to at least a moderate degree, have a plan to manage it.
5. Seriously ill palliative care and hospice patients have a documented discussion regarding emotional needs.
6. Hospice patients have a documented discussion of spiritual concerns or preference not to discuss them.
7. Seriously ill palliative care and hospice patients have documentation of the surrogate decision-maker’s name (such as the person who has healthcare power of attorney) and contact information, or absence of a surrogate.
8. Seriously ill palliative care and hospice patients have documentation of their preferences for life-sustaining treatments.
9. Vulnerable elders with documented preferences to withhold or withdraw life-sustaining treatments have their preferences followed.
10. Palliative care and hospice patients or their families are asked about their experience of care using a relevant survey.
