Health Professionals Prepare Amidst the Uncertainty

On the unusually cool last day of May, at the Lockton headquarters high

above the Country Club Plaza, a score of local health-care leaders met to sort

out the present and future of health care in the Kansas City area and beyond.

This was the 13th annual Health Care Industry Outlook orchestrated

by Ingram’s Magazine. Sponsoring the event were the Lockton Companies and

Blue Cross Blue Shield of Kansas City, also known as Blue KC. Ably co-chair-

ing the event were Rick Kahle, president of the benefits operation at Lockton,

and Danette Wilson, Blue KC’s group executive for external operations.

In a time of uncertainty—the Supreme Court ruling on health-care

reform is expected by the end of this month—the participants seemed well-

prepared to deal with the future—whatever that future might be.

Healthcare Industry Outlook

(front row, left to right)Rick Kahle, Lockton Companies

(Co-Chair and Co-Sponsor)Brian Stewart, Athletic

& Rehabilitation CenterGary Stanton, Women’s Health NetworkDanette Wilson, Blue Cross Blue Shield

of Kansas City (Co-Chair and Co-Sponsor)Christine Wilson, Mid-America

Coalition on HealthCareCarolyn Watley, CBIZ Benefits &

Insurance ServicesFrank Devocelle, Olathe Health System

(second row, left to right)Dr. Jeffrey Kramer, Univ. of Kansas HospitalLori Mallory, Kansas City Internal Medicine

Jill Watson, Metro MedJill Ebbers, Children’s Mercy Hospital

Dr. Stephen Salanski, HCA MidwestDr. Nathan Granger, Clay-Platte

Family Medicine ClinicDr. Ian Chuang, Lockton Companies

Dr. Mark Laney, Heartland Health

(back row, left to right)Dayna Hodgden, Encompass Medical Group

Chris Hansen, Univ. of Kansas HospitalKevin Sparks, Blue Cross

Blue Shield of Kansas CityScott Helt, Univ. of Kansas Hospital

Evan Peters, Cigna

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Sponsored by:

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IT Readiness

Likemanyoftheparticipants,Dan-etteWilsonwasnotinclinedtospeculateonhowtheSupremeCourtmightrule.If nothing else, Wilson believes thatthe move to reform has sparked somenew conversations among the peoplearoundthetable.Oneconversationhasbeen about information technology.Shewonderedwhetherthehealthcom-munitywastoadapttoanychangesinlawandtotakefulladvantageofexist-ingtechnology.

ChrisHansen,seniorvicepresidentatUniversityofKansasHospital,spoketothecatchphraseof“meaningfuluse.”As he explained, the government iswilling tohelphospitalsandothereli-gibleprovidersautomatemedicalrecordsiftheydosoina“meaningful”way,onethataccruesobviousbenefits.

One of the meaningful variables isquality.Tomeasurethis,however,requiresdoctors to do a lot of box-checking onquestionslike,“Didyoutalktothepatientaboutnotsmoking?”Thistendstoslowdoctors down. Still, Hansen remainsoptimistic.

“If you can get past the productiv-ity issues with the system and someof the negative aspects of having todocument things that people mightnot feel they should have to do,” saidHansen, “you’re going to have data intherethatactuallyyoucantransmittosomebody, that you can actually useproactivelytomanagethecare.”

In that his system just went live afewweekago,NathanGranger,afamilyphysician with the Clay-Platte FamilyMedicineClinic,hehadsomefreshexpe-riencetoshare.Ashenoted,aphysicianwithachronically illgeriatricpracticehasbeencreatingpaperchartsfor20orsoyears.Trying to transformthat intoanelectronichealth recordwhile run-ningfullblasttotakecareofafullpanelofpatients,saidGranger,“isdaunting.”It has taken his practice a few yearstomakethattransformation.

Hansen observed that hospitalsworkingwithBlueKCcanpre-loadintotheir systems information on patientswithchronicillnesses.Still,hedoesnotknow how small hospitals or doctor

officesmanagethetransition.Hewon-dered whether mandatory automationwould“forceconsolidationofprimary-careprovidersbecausetheycan’taffordtheITinfrastructure.”

“I’ve talked to hospital executiveswhoexpecttheretobemoreconsolida-tions,”confirmedJillWatson,executivedirector of the Metropolitan MedicalSociety. Some physician practices, she

RIGHT AT HOMEBlue Cross Blue Shield of Michigan reported last year that its first foray into cost reductions through patient-centered medical homes had provided promising evidence of their ability to reduce the overall costs of health care. Among them:

• A 2 percent drop in radiology visits for covered patients. • A 1.4 percent reduction in adult emergency-room visits. • A 2.2 percent drop in pediatric emergency-room visits. • A 2.6-percent decline in inpatient admissions. • Overall patient care costs fell about 1.2 percent.

While no huge swings in any one category, when spread out across an insured base of 2 million people those numbers represent a significant improvement in the health-care cost curve, Blue Cross officials say.

1. Rick Kahle saw huge benefits coming from patients’ having ready access to their health records. | 2. Danette Wilson asked the probing question of whether health-care information technology was as advanced as it needed to be. | 3. Nathan Granger said IT challenges required huge investments of time from staff and physicians. | 4. Chris Hansen noted that, once the productivity issue was resolved, use of data could improve the quality of care.

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1. Mark Laney pointed out that using physicians for routine conversations was an inefficient use of an expensive health-care resource: A doctor’s time. | 2. Dayna Hodgden said about 25 percent of patients at Encompass Medical Group make good use of their available records. 3. Evan Peters saw the benefits of records access as a patient, and said his own doctor real-ized those, as well. | 4. Frank Devocelle questioned how the concept of “best practices” in health care would be defined—and by whom.

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explained, are choosing to consolidatewiththeirhospitals“sotheydon’thavetomakethechoices.”

StephenSalanski,afamilyphysicianwithHCAMidwestandprogramdirec-tor at the Research Family MedicineResidencyprogram,hasobserved thechallenge from a number of angles.HCA,alargenationalenterprise,wasone of the first systems in the coun-try to move to electronic records.And yet, as Salanski noted, HCA is“stillhaving troubleswithprocessingand moving our old records into thesystem.”

Paperwork,orthedigitalequivalent,is takingmore timenow,not less,and“meaningful use” is still not what itshouldbe.“I’vetalkedtocolleagues inothersystems,”saidSalanski,“andeverysystemseemstobelagging.”

GaryStanton,executivedirectorofthe Women’s Healthcare Network, be-lievesthattheInternet-savvyconsumerishelpingdrivethemovetoautomation.One of the problems his organizationhas encountered in responding is thecost in time and money of training.“There’s only so much time,” he said.Getting physicians trained is “cum-bersome at best,” especially for thoseproviderslack-ingtheproperresources.

Fromtheconsumerperspective,RickKahle sees “huge benefits” in gettingaccess to relevant health information.Heaskedhiscolleagueshowpushbackfrompatientshadchangedrelationshipsintheworldofelectronicrecords.

HCA is going to go on a live-linepatientportalthissummer,saidSalanski.Patientswillhaveaccesstosomeoftheirrecordsandlabresultsafterthesehave

beensignedoffbyaphysician.“We’realittlenervousaboutwhatthatallmeans,”said Salanski, “and how that changesourinteractionswithpatients.”

EncompassMedicalGroup,observedCEODaynaHodgden,has32physicianswhohavemet“meaningfuluse”criteria.Encompass has been using electronicmedical records since 2008. “We hadto commit a lot of resources and hirequiteafewpeopletomakethatsystemwork for them,” said Hodgden. Todate, though, only about 25 percent ofthe patients have taken advantage ofthepatientportal toaccess theirdata.When they do use it, Hodgden added,“ithasbeenagoodthingforthepatients.”

ChrisHansenseesthevalueinpat-ientaccess,butcautioned thatdoctorshavetobeverycarefulaboutthelang-uagetheyuse,lestpatientsfailtounder-standit.Asecondaryissue,ofcourse,isreimbursement.Technically,thereisnoneforelectronicpatient-doctorexchanges,eventhosethataretimeconsuming.

“From the patient’s side of things,”said Evan Peters, the vice-president ofnetworkmanagementforCignaHealthCarePlanofMid-America,“I love thissystem.”Anearlyadapter,heregularlycommunicates with his own physicianelectronically. “I love the ability to dothat, but I understand there’s a costassociated with this system and some-thinghastosupportthat.”

CollaborationRick Kahle asked his colleagues

whether “health-care silos” were giv-ing way to new collaborations amonghealth-careentities.

Mark Laney, the president and CEOofHeartlandHealthandapediatricneu-rologist by training, explained that phys-icians were effectively “siloed” in theirprivate practices and lacked electronicmedicalrecordswithwhichtocommuni-cate.Thismadeithardtocoordinatecare.

Now,Laneybelieves,“Wefaceadif-ferentkindofsilo.”Heattributesthistoa growing “shift mentality.” Not want-ing to work the hours older physiciansonce did, younger physicians practiceinsuchawaythattheremaybetwoorthree“handoffs”ofpatientsoveraperiod

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of several days. This may lead to someconfusion, added Laney, about “who’smy doctor?” Given this development,electronicmedicalrecordsbecomemoreimportantas“thesourceoftruth.”SaidLaney,“Ithinkit’scriticallyimportantthatwepracticeevidence-basedmedicine.”

“I think we’re going to see morestandardization,”saidFrankDevocelle,president and CEO of Olathe MedicalCenter.Heseestheindustry“headedto-wardbestpractices.”AlthoughDevocellethinksthiswillbegoodforthepatient,he seesaneed foradefinitionofwhat“bestpractice”means.“Idon’tknowifthatlieswiththeinsurancecompaniesorgovernment,”headded,“butIthinkthereneedstobesomedirectiongiven.”

According to Evan Peters, one oftheservicesCignahasbeenrollingoutacrossthecountryisknownasa“collab-orativeaccountable-careorganization.”With these integrated arrangements,saidPeters,“Itcan’tjustbetheunitcostyou’re looking at. It has to be the out-comes.Ithastobethequality.Ithastobethepatientsatisfaction.”

DanetteWilsonaddressedtheevolu-tionofpatient-centeredmedicalhomes,nowintheirfourthyearofoperationinKansasCity.Basically,thosearehealth-care settings that create partnershipsbetween patients and their personalphysicians and, at times, the patient’sfamily. The concept depends on infor-mation technology,health-informationexchange, registries, and other aids toensure that patients get appropriatecarewhenandwheretheyneedit.

“One of the things we are doingthrough that model,” said Wilson, “ispayingforcarecoordination,payingforthings that carriers have not paid forin the past.” Wilson contended thatmostcarriers recognize that the tradi-tional fee-for-service arrangement willnotbesustainableinthefuture.

Consumer ExpectationsDanetteWilsonworriesaboutthose

patientswhothinktheWebisthe“sourceof truth.” She wondered how access tomedicalinformationhadchangedthewaydoctorsapproachbringingcaretopatients.

“Our job,” said Mark Laney, “is toprovidethesitesthatwethinkareevi-dence-basedandareexcellentsourcesofinformation.”Headdedthatthehealth-care industry could not achieve whatithopedtounlessithadengagedpatients.

DanetteWilsonbelieves,infact,thatpatients have been getting more andmoreengaged.Shetoldofhearingagooddeal from consumers about issues liketransparencyandaccesstoinformation.Sheaskedhercolleagueswhatprovidersweredoingtoprepareforincreasedcus-tomerdemandsforaccesstoinformation.

The University of Kansas Hospital,saidScottHelt,vicepresidentofcontract-ing,hasalreadysetuppatientresourcecenterswithplentifulliteratureandeasyInternet click access to good, trustedinformation. “This makes it easier forthe patients to get information that isvalidated and is evidence-based,” saidHelt, “as opposed to ‘Uncle Harry hadthesamething50yearsago.’”

Evidence-Based Medicine

ChristineWilson,presidentandCEOoftheMid-AmericaCoalitiononHealth-Care, sees a constant improvement inthedevelopmentofevidence-basedcare.One reason why is that employers inKansasCityarewatchingitsprogressveryclosely.Thatmuchsaid,Wilsonacknowl-edged a substantial lag time betweena given innovation and its widespreadadaptation.Still,shehasbeenencouragedbythecollaborativeeffortofKansasCity-areaprovidersinsharinginformation.

Brian Stewart, chief marketingand clinicians officer for the AthleticandRehabilitationCenter inOverlandPark, spoke to the issue of collectinginformationfromemployerstoimproveoverall servicedelivery.Hecitedthreereasonsforthiseffort.

One is to create a model of an “ac-countable consumer” and an “account-ableprovider.”Twoistoreviewthedatainternally to see which clinicians aredoing thebest joband topartner themwithclinicianswhocouldusetheirassis-tance.Thirdistobeabletomakeplan-ningdecisionsthataretruly“objective.”

RickKahleaskedhiscolleagueshowthey could leverage information to getthebestoutcomes.IanChuang,medicaldirectorandseniorvicepresidentatLock-ton,expressedsomecautionabouttheuseofdataatthisstage.Giventheinevitableinconsistencies, Chuang suggested thatprovidersdefineastandard,practice it,analyze it, and figure out if there isa way to do it better by looking at the

1. Scott Helt noted the emergence of patient resource centers that help people learn more about their own health. | 2. Brian Stewart said that accountable health care had to include accountability for both the insured worker and his company. | 3. Gary Stanton cited the high costs of training as an issue for medical offices incorporting new technologies.

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data. The challenge now, he said, is totietheclinicaldatawithgroupdatafromsome of the higher-level employers andassesstheimpact.

“Thenextstep,”addedChristineWil-son, “is to make sure that the inform-ationisinaformatthatitcanbegivento a patient or to a caregiver, so thatthey can make an informed decisionwiththeirphysician.”

Chuangworriedopenlyaboutthebuzz-wordsofcosttransparency.“Inourpur-chasingpatterns,”hesaid,“wedon’tus-uallywanttobuythecheapest,becauseweknowthere’ssomethingyougiveup.”

“I thinkwewould like tobephysi-cian-driven,” said Kevin Sparks, groupexecutive for internal operations atBlueKC.Forhisorganization, innova-tionmeanskeepingtheproviderattheheartofthepatientcare.Heconceded,though,thattheindustryisinsomething

ofamarketshift,withtheconsumernowinthemiddleandtheprovidercirclingtheperipheryoftheuniverse.

After Fee-for-Service“Whatopportunityexists,”askedRick

Kahle provocatively, “for moving awayfromfee-for-servicetosomethingelse?”

Stephen Salanski sees some move-ment away from this traditional feearrangement,giventheemergenceofthepatient-centeredmedicalhomeconceptand other innovative arrangements.Physicians who are doing more workby e-mail or by phone and proactivelycaringforpatientswhentheytransitionfromthehospitalbacktotheofficeareperformingservicesthatdefytraditionalfeearrangements.Ifprovidersandpayersbegintoacknowledgeandprovideincen-tivesforthesekindsofpractices,Salanskibelieves,higher-valuecareshouldfollow.

“We’d like to see more insurancecompanies focus on shared savingsmodels and care-coordination fees,”affirmed Lori Mallory, CEO of KansasCity Internal Medicine, “because webelievethatif[allparties]areintheroomtogetherthatwecan,infact,reducethecost and improve the quality.” AddedMallorytogeneralapproval,“Obviously,Ipreferamarketorientationtogovern-mentauthorityonthisissue.”

Chris Hansen expressed providerfrustration with the fact that each in-surer has a distinct reimbursementmodel. “We can’t have eight differentcare models reimbursement-wise orPCMH-wise,” saidHansen.“We’re justgoingtokillourselves.”

“It’snotjustthedifferentinsurancecompanies,”saidMarkLaney.“Physiciansdon’twanttohavetwoclassesofpatients.Theydon’twanttobeinafee-for-servicemindsetwithMrs.Smithandinvalue-basedmindsetforMr.Jones.”

AsRickKahleobserved,thereistalknowwithintheIRSthattheaffordabilitytestwouldbebaseduponfamilycover-age.Thismeansthatanindividualcouldpaynomorethan9.5percentofhisorher household income towards familycoverage.Ifmore,itwouldnotbedeemedqualified affordable family coverage,in which case the individual could goto a health-insurance exchange. Ofcourse,thiswholeconceptcouldbeun-donesoonbytheSupremeCourt.

Wellness“One of the things that we know

is that employers don’t like increasedregulationandcomplexity,”saidCarolynWatley, president of CBIZ Benefitsand Insurance services. The role ofCBIZ and other consultants, Watleyexplained, is not just to get the infor-mation out to clients, but to get it outcorrectly,sothatclientscanplanwithatleastsomeconfidence.Oneareathathas enthused CBIZ is the employer’sembraceofwellnessasawaytoimproveworkerhealthandproductivity.

Whenaskedwhetherwellnessreallypays dividends to the employer, Wat-ley answered confidently, “We knowthatwellnesspays.”RickKahleagreed.

1. Lori Mallory said it was important that insurance companies focus on shared-savings models. 2. Kevin Sparks said innovation in health care means keeping the provider at the center of delivery efforts. | 3. Stephen Salanski suggested that higher reimbursements should follow higher levels of health-care delivery. | 4. Carolyn Watley noted the need to get better infor-mation out to workers, who could then make better decisions about their own wellness.

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-9% -6% -3% 0 3% 6% 9% 12% 15%

Theaccumulationofriskfactorsmakesmeasurement difficult, but not impos-sible.Measurement,heacknowledged,accomplishes little unless employersalsoprovideincentivesandleadershiptomakesuregoalsareaccomplished.

“There are so many things that youcandotohelpimpacttheproductivityoftheworker,”affirmedCarolynWatley,“andhelppositivelyimpactthebusinessaswell.”

Ian Chuang expressed his satisfac-tion in seeing even small companiesgetcreativeindesigningandsustainingwellness movements. “Employers arealso starting to expand that definitionofhealthandwell-being,”saidChristineWilson.Thisexpandeddefinitionmightincludefinancialwell-being,socialcon-nections,careersatisfaction,mentoringandanynumberofothervariables.

A nearly universal problem, severalparticipantsnoted,wasobesityintheworkforce,eveninthehealth-careworkforce.“IfIwasgoingtogive[employers]solu-tionsonhowtofixtheirworker’scomp,”said Brian Stewart, “I would tell themtheyneed toaddress theirobesitywitheveryone,notjusttheirinjuredworkers.”

As Danette Wilson noted, health-related observations have a particularobligationtopromotewellness,andmanyaredoing just that.KevinSparksaffir-medthatBlueKChascometorecognizethat voluntary participation in a well-ness program is not always sufficient.Reinforcementandguidancearecritical.

Children’s Mercy has its fair shareof overweight employees as well, saidJill Ebbers, director of the hospital’smanaged-care program. One responsehas been the creation of a successfulprogram called “New Year, New You.”This involves teamsof fourcompetingover a 16-week period. The hospital,said Ebbers, has hired fitness coachesand has done much to encourage itsemployeebasetoparticipate.

Rick Kahle asked how employerssustaintheseprogramsandkeepemployeesengaged.Theemployerhastovaluehealth,andtheemployeeshavetoknowit.Then,saidCarolynWatley,thereisanunderstand-ingbytheemployeethat“IbettergetonboardorImightwanttofindahomeelse-wherebecauseI’mnotgoingtofitinhere.”

“Weasanorganizationhavetointer-ruptbehavioralpatternsthatdisrupttheorganization,” agreed Rick Kahle, andseniorleadershavetodrivethatunder-standing.LoriMalloryaddedthecautionthat management not be too heavy-handedinpushingparticipation.“Idon’twanttotakethefunoutofit,”shesaid.

“I would think that your primarycare physician is your best teacher ofwellness,”saidChrisHansen,addinganew wrinkle. “Most people listen totheir doctor. If your doctor tells younot to do something, it’s going to bea lot more powerful than your peersor group.” One challenge, of course,istogetthedoctorsinvolved.

Asecondchallenge,MarkLaneyadd-ed,isthat,“you’reaskingthemostexpen-sivepersonon thehealth-care teamtodoeducation.”Heartland,whichisself-insured, has kept its premiums stable

the last three years, in part by doinghealthassessmentsforeveryemployee,spouse and child that it covers and byproviding only healthy food to itsemployees.“Wegottothepointwherewe thought if we’re really going totalk about this with the community,”saidLaney,“wehavetoliveourvalues.”

“As an employer and a provider ofthecommunity,”saidRickKahle,“youhave the unique opportunity to makethoseculturaldecisions.You’reprovid-ing so much of the care for your ownpeopleandyoucanmakean ‘account-ablepatient.’Theintegratedhealth-caresystems are in a unique position tosolvethisproblem.”

Goingforward,DanetteWilsonalsosawrealopportunityinworkingcollab-oratively.“Therehavebeenalotofgoodconversations,”sheaddedoptimistically,“andwethinkthingscangetbetter.”

1. Ian Chuang noted that even smaller companies are getting on the wellness wagon to design plans for improving the health of their work forces. | 2. Jill Ebbers cited the success of an in-house employee wellness program at Children’s Mercy Hospitals and Clinics. | 3. Financial, social and career well-being are all part of a broader definition of employee wellness emerging in many workplaces, said Christine Wilson.

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