Insigniam Quarterly 2014 Special Edition - Healthcare

S P E C I A L H E A LT H CA R E I S S U E 2 014

HEALTHCAREAN INNOVATION MANIFESTO

INSIGNIAM QUARTERLY’S

HEALTHCARE OVERVIEW

“In the increasingly complex healthcare marketplace of today, innovation is not a nice-to-have; it is essential for simply

surviving. At the same time, potent innovation can also be a source of

sustainable success, especially when the creativity and contributions of the people

of an enterprise are unleashed and the execution of new possibilities is reliable.”

— SCOTT W. BECKETT

LETTER

WWelcome to this special edition of Insigniam Quarterly, which focuses on today’s

global healthcare industry. While transforming healthcare means different things

in different geographies, we have found that a vast majority of the issues are

actually the same. As individual and business consumers of healthcare, we often

do not see the background forces that are radically disrupting the resources

and money available for our care. Healthcare executives know them all too

well: shifting demographics, increased incidence of noncommunicable diseases,

greater emphasis on wellness and value-based reimbursements, higher patient

involvement and accountability, etc. Together, these issues have all the makings of

a wicked, seemingly impossible problem to solve. However, when broken down,

there is a path to success that offers unprecedented opportunity.

Although we don’t have all the answers, we do know that the path starts with

innovation. Through our experiences working with healthcare organizations,

we’ve identified what we believe are critical success factors we will all need in

our back pocket on our journey to reshape the future of healthcare. What is it

to be accountable for our health? What does it take for a healthcare system to

become indispensable? How can the entire patient experience be reinvented?

Is it possible to embed innovation into an organization as a core competency?

What about creating a mindset of well-being and expanding our horizons for

access and delivery of care? Do you aspire to be a transformational leader in

healthcare? Have we put the right technology in place? Is our healthcare culture

guided by responsibility and accountability? Are your physicians integrated with

a diversity of specializations?

While overwhelming in the aggregate, we hope to help answer some of these

questions in this special issue, leading us all to a clearer vision. Consider it a

healthcare manifesto, a playbook of sorts, outlining critical success factors to keep

on your radar as we counter — and overcome — real-world, disruptive forces

occurring around us. Know that the same forces that are turning our world upside

down today, are leading us toward a better future. This is a rare moment in time.

This is our moment to transform healthcare itself.

Game on.

Shideh Sedgh Bina

Founding Partner, Insigniam

SPECIAL HEALTHCARE ISSUE 2014 INSIGNIAM QUARTERLY 1

OUR TIME IS NOW

SPECIAL HEALTHCARE ISSUE 20142 INSIGNIAM QUARTERLY

12INDISPENSABILITYMake the patient an offer, and give them an

experience, they can’t refuse. 16REINVENTING THE PATIENT EXPERIENCEIf solutions begin by focusing on the patient, let

patient-centric care be your guide.

20GETTING MORE FOR LESSOutdated revenue models will cripple your returns.

The path to efficiency — and profitability — may be

simpler than you think.24

DIVERSIFIED, YET INTEGRATED SPECIALIZATIONHow a physician leadership network and a focus

on population health is putting the heart back into

healing.

FEATURES

DEFINING SUCCESSThe key to cracking

healthcare’s wicked

problems requires a

“different agenda”.

OVERVIEW04

TABLE OF CONTENTS


EDITOR-IN-CHIEF Shideh Sedgh Bina

[email protected]

EXECUTIVE EDITOR Nathan O. Rosenberg

[email protected]

CHIEF FINANCIAL OFFICER Ralph Gotto

DIRECTOR OF WORLDWIDE Karen Turner

CLIENT SERVICES [email protected]

DIRECTOR OF SPECIAL PROJECTS Alexes Fath

PUBLISHER Gordon Price Locke

[email protected]

EDITORIAL DIRECTOR Amy Robinson

[email protected]

GUEST EDITOR Liz Willding

MANAGING EDITOR Jonathan Ball

[email protected]

EDITORIAL CONTRIBUTOR Ira Katz

[email protected]

CREATIVE DIRECTOR Kyle Phelps

[email protected]

ASSISTANT ART DIRECTOR Emily Slack

PRODUCTION MANAGER Pedro Armstrong

IMAGING SPECIALIST John Gay

DIRECTOR, ACCOUNT SERVICES Jas Robertson

ACCOUNT SERVICE MANAGER Joan Khalaf

EDITORIAL QUERIES

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Dallas, Texas 75201

www.dcustom.com

214.523.0300

For advertising information, contact Jas Robertson at

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Insigniam Quarterly is published by D Custom, 750 N. Saint Paul Street, Ste. 2100, Dallas, Texas 75201. Copyright 2014 by Insigniam. All rights reserved. Letters to the editors may be sent to Insigniam Quarterly c/o D Custom, N. 750 Saint Paul Street, Ste. 2100, Dallas, Texas 75201. No part of this publication may be reproduced in any form or by any means without prior written permission of the publisher and Insigniam. Printed in the U.S.A. Magazine patents pending. For subscriptions, please visit www.insigniamquarterly.com.

Q U A R T E R LY

SPECIAL HEALTHCARE ISSUE | 2014

“People don’t often seek care due to the deep fear of the

complexity of the cost, and because they don’t feel we are

listening to their needs. We need to understand their reasons.”— DOUGLAS L. WOOD, M.D.

DIRECTOR OF THE CENTER FOR INNOVATION, MAYO CLINIC

MINDSET OF WELL-BEINGShifting the focus is all about engagement

NEW HORIZONSA model for the future of healthcare: Women’s College

Hospital

HEALTHCARE LEADERS, OUR TIME IS NOW“Innovation” is today’s critical objective

LEVERAGING NEW TECHNOLOGYTake technology to a personal level

TRANSFORMATIONAL LEADERSHIPFor Cone Health, “unleashing the tiger” of transfomation

begins with empowerment

HOW WELL ARE YOU FULFILLING YOUR PROMISE?Accountability is more than just lip service. It’s strategy.

IQ BOOST

Infographic: RX For Success

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ADDITIONAL FEATURES

Woman of the Year Award Congratulations to our editor-in-chief, Shideh Sedgh Bina, on being named a “Woman of the Year” by the Healthcare Businesswomen’s Association. For more on this award, visit www.insigniamquarterly.com/HBAaward

Insigniam and its publisher, D Custom, distribute this editorial magazine to share the opinions and insights of companies and their leaders on impactful global business issues. Insigniam Quarterly’s inclusion of a company or individual does not indicate that they are a client of Insigniam. Remuneration is not provided for editorial coverage. Individuals appearing in Insigniam Quarterly have done so with direct consent, or provided consent by a designated authorized agent in addition to being disclosed on the magazine’s audience and purpose.

4 INSIGNIAM QUARTERLY

DEFININGSUCCESSCracking healthcare’s wicked problems requires a “different agenda.”

BY LIZ WILLDING

SPECIAL HEALTHCARE ISSUE 2014

INSIGNIAM QUARTERLY 5

INSIGNIAM HEALTHCARE OVERVIEW



In every respect, today’s global healthcare challenges fit the

definition of a wicked problem, essentially a moving target that

is difficult, if not impossible, to solve (see the 10 characteristics

of wicked problems in the accompanying sidebar).

At Insigniam, we believe a number of disruptive forces

are in play today that indeed make healthcare a wicked nut

to crack. Most healthcare executives are well aware of the

challenges, which start with shifting demographics resulting

in a predicted tsunami of older, more diverse patients with

chronic noncommunicable diseases. (NCDs). To counter this,

the industry is logically shifting to population health, which

demands a focus on wellness and value versus the old volumes-

based model to treat illnesses. While there is no dispute that

technology — from electronic health records to a plethora

of digital health tools — is proving to be a big part of the

solution, implementation is arduous and costly, and the real

gains expected from integration are still on the horizon. Factor

in increasingly involved patients who want to know where

their money is going, and it is enough to make any healthcare

executive’s head spin. Then there’s projected provider shortages,

increased regulation, and shrinking access to capital to contend

with.

While all of this may seem daunting and truly wicked, we

suggest that focusing on a handful of critical success factors

can facilitate reinvention and innovation despite today’s chaotic

healthcare environment. The process begins by asking hard

yet provocative questions. “What are the key variables that

leaders should have on their radar as they attempt to reinvent

healthcare? What will it take, as an industry, to turn today’s

enormous healthcare ‘cruise liner’ in the direction of wellness?

How will technology help enable patients as they assume more

responsibility for their own care?” While there are no easy

answers, Insigniam Quarterly turned to a number of industry

experts for context and insight into critical success factors for

10 of the top issues facing the healthcare industry for 2014

and beyond.

GLOBAL TRENDSIn the landmark study “Global Burden of Disease, 2010,”

healthcare leaders viewed a snapshot of key demographic

changes that are fundamentally changing healthcare delivery.

The study documented that global life expectancy for males

and females had risen more than 10 years from 1970 to 2010,

reaching a global average of 67.6 and 73.3, respectively. Even

more revealing, more deaths occurred globally at 70 years of

age or older, with 22.9 percent, almost a quarter, occurring at

80 years or older.

In contrast, the study noted that deaths from

noncommunicable diseases eclipsed those of infectious diseases

during the same time period, killing more than 35 million people


When Horst Rittel and Melvin M.

Webber coined the concept of

wicked problems in 1973, they were

largely talking about policy issues

— however they might as well have

been referring to modern healthcare.

OVERVIEW


yearly — accounting for nearly two-thirds of the world’s

deaths. Why? According to the World Health Organization

(WHO), it’s a matter of priorities. In its “2008-2013 Action

Plan for the Global Strategy for the Prevention and Control of

Noncommunicable Diseases,” WHO reported that “NCD

prevention and control programs remain dramatically under-

funded at the national and global levels,” and noted that NCD

prevention was “currently absent from the Millennium

Development Goals,” established by the United Nations

with a target date of 2015. If allowed to go unchecked, the

report estimates that NCDs will increase by 17 percent over

the next 10 years.

While “increased longevity represents success against

infectious diseases,” says Roger

I. Glass, M.D., Ph.D., director

of the Fogarty International

Center at the National

Institutes of Health (NIH),

the pendulum has clearly

swung in the other direction.

“What are we going to do

with our aging populations

who are suffering from

diabetes, heart disease, cancer,

and other noncommunicable

conditions? It suggests a

completely different agenda.”

The irony is that the

vast majority of NCDs are

preventable and could be

reduced or eliminated through

increased patient support. In

this sense, Dr. Glass says it is

time that preventive programs

aimed at addressing lifestyle

issues catch up with scientific

advances. According to WHO,

up to 80 percent of heart disease, stroke, and Type 2 diabetes,

and more than a third of cancers, could be prevented by

eliminating shared risk factors, which include tobacco use,

unhealthy diet, physical inactivity, and harmful use of alcohol.

“The issues are the same worldwide,” says Elizabeth H.

Bradley, Ph.D., who is faculty director of the Yale Global

Health Leadership Institute. “The big question is whether

reimbursements based on services related to treating illness

versus funding preventive programs will keep up with the

demographic and epidemiological shifts resulting from

an aging population and the epidemic of obesity,” which

contributes to NCDs.

In the U.S. alone, she notes that one-third of the

population is obese, with the cost of care per patient

estimated at approximately $5,000 more per year than nonobese

patients. “This is very taxing to medical systems and executives

who are looking at the long run and struggling to deal with it.”

TURNING THE SHIPWhile reinventing healthcare is indeed a wicked problem,

a number of demonstrated critical factors can provide

healthcare executives with a path toward an elevated

likelihood of success.

“The process starts and ends

with having the patient’s best

interests in mind,” says Dr.

Bradley. “You have to frame

your products and services so

customers really want to come

to you. It boils down to putting

the customer first.” This means

looking at problems through the

patient’s eyes, becoming a partner

in their care. It is everything from

reducing wait times and billing

errors to supporting them with

wellness programs to achieve

lifestyle changes.

Adds Douglas L. Wood,

M.D., director of the Center for

Innovation at the Mayo Clinic,

it is important to approach

any problem in the context of

“transforming the way people

experience health and healthcare.”

He notes that “understanding

why people do what they do,” is the starting point. “First,

people don’t often seek care due to the deep fear of the

complexity of the cost, and because they don’t feel we are

listening to their needs. We need to understand their reasons.”

As organizations seek to innovate and reinvent themselves,

they should also be cautious not to rely on a cookie-cutter

approach, says Nathan Owen Rosenberg, Insigniam founding

partner. “It is a big mistake to copy what other enterprises

have done to innovate. The success we see in designing new

methods for value and access for patients are successful because

they have been invented — not merely copied. Sustained

“IT IS A BIG MISTAKE TO COPY WHAT OTHER ENTERPRISES HAVE DONE TO INNOVATE. THE SUCCESS WE SEE IN DESIGNING NEW METHODS FOR VALUE AND ACCESS FOR PATIENTS ARE SUCCESSFUL BECAUSE THEY HAVE BEEN INVENTED — NOT MERELY COPIED.”

OVERVIEW


innovation requires a leadership mandate for innovation,

proprietary innovation processes, and an infrastructure that

plays to the strengths and ambitions of your enterprise. And,

of course, unless changes are supported by the exisiting culture

they are rarely sustained long term.”

Ensuring that the revenue cycle is running like a well-

oiled machine is another key variable, says Jennifer Zimmer,

Insigniam partner, noting that most are archaic and rooted in

the past pay-for-services model. “This makes it difficult and

frustrating for patients because a significant touch point in their

experience is not user-friendly nor is it value-added for the

patient. Innovation is about building a revenue cycle where

each touch point enhances the patient experience and shows

added value.”

Regardless of the geography, tomorrow’s revenue cycle

must focus on value, especially to keep up with trends such

as personalized medicine, says Corinne Le Goff, president of

Roche SAS. “In oncology,” she explains, “different biologics

are often combined for treatment, but, ‘how do you bill for it?’

We need to have a system that allows for reimbursement in a

more personalized way.”

All of this begs for new business processes that keep pace

with those occurring in science. “We believe it is by bringing

the best minds around the table that you find the solution,”

Le Goff adds, “which includes partnerships with academia.”

Alex Gorsky, CEO of Johnson & Johnson, agrees, but

cautions, in a March 2013 interview with CNBC, that the way

forward will also “involve trade-offs, and participation from all

aspects of society. When you think about the aging population,

when you think about the demographics … it is hard not to

talk about healthcare in the context of the economy and the

systemic issue of how we somehow find a way to provide high

quality, affordable healthcare in a sustainable way.

“It first starts with ‘where do we think the unmet medical

needs are going to be?’” he explains. “If you look at the data,

it suggests cardiovascular disease, Type 2 diabetes, Alzheimer’s

— all are going to be cost drivers, particularly in an aging

population where there is a higher incidence rate and very

high costs are associated with them.” Part of the challenge,

Gorsky adds, “is being disciplined about where you do — and

don’t — invest.”

Because lifestyle-related conditions are front and center,

industry experts around the globe are in agreement that a big

part of the solution resides with primary care, integrated with

the specialties, to serve the needs of the whole population. In

the quest to achieve population health, “it’s about hospitals and

physicians working together,” says Dr. Bradley, with physician

leaders taking a major leadership role. She notes, however, that

CRITICAL SUCCESS FACTORS

IN HEALTHCARE DRIVING

REINVENTION AND INNOVATION,

COMPILED BY INSIGNIAM FROM

INDUSTRY DATA, INCLUDE:

INDISPENSABILITY

REINVENT PATIENT EXPERIENCE

NEW REVENUE CYCLE

DIVERSIFIED, YET INTEGRATED SPECIALIZATION

MINDSET OF WELL-BEING

NEW HORIZONS

EMBEDDED INNOVATION

LEVERAGING NEW TECHNOLOGY

TRANSFORMATIONAL LEADERSHIP

CULTURE OF RESPONSIBILITY AND ACCOUNTABILITY

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“there is a lack of understanding on adaptive leadership in both

middle and upper management,” suggesting that medical and

professional leaders alike must sharpen their skills to effectively

react to the shifts that are occurring. This includes supporting

creativity and innovation within their organizations, as well as

developing the interpersonal skills needed to partner effectively

with physicians and care providers.

USING TECHNOLOGY TO ENGAGE PATIENTSInnovative use of technology also is expected to “take care

to the people,” says Patricia Abbott, R.N., Ph.D., an associate

professor at the University of Michigan School of Nursing

Office of Global Outreach. Dr. Abbott spoke about the use

of wireless technology to engage vulnerable populations at an

“Innovations for Global Health” conference hosted by U-M.

She referenced her study in inner city Baltimore that monitored

heart patients at home using mobile health (mHealth) devices.

“The mHealth intervention used wireless technology with

Bluetooth scales and blood pressure cuffs. It also used video

telephony (similar to Skype) and touchscreen computing to

deliver tailored messages, quizzes, and reminders. Within the

computer was a patient-owned personal record, which was

incredibly valuable in creating partnerships and engaging

patients in their care.”

As information technology proliferates, she stresses the

importance for the industry to create an interoperable and open

digital ecosystem, saying, “Access to, and sharing of, information

is a basic tenent for improving health, both in the U.S. and

abroad.”

This ecosystem includes payers and the private sector, who are

innovating rapidly with tools to assist people in monitoring their

own health, ultimately driving greater personal responsibility. A

big part of driving compliance can be achieved by empathizing

with patients, helping them address life issues, and rewarding

their successes. “The behavior modification concepts are global,”

says Joan Kennedy, Cigna vice president, customer health

engagement, noting that the industry is leaning toward virtual

interventions with incentives built in to reward success, which

can include everything from receiving a gift card for completing

OVERVIEW

In their 1973 treatise “Dilemmas in a General Theory of Planning,” Rittel and Webber noted that wicked problems have 10 characteristics:

Wicked problems have no definitive formulation. Formulating the problem and

the solution is essentially the same task. Each

attempt at creating a solution changes your

understanding of the problem.

Wicked problems have no stopping rule. Since you can’t define the problem in any single

way, it’s difficult to tell when it’s resolved. The

problem-solving process ends when resources

are depleted, stakeholders lose interest, or

political realities change.

Solutions to wicked problems are not true-or-false, but good-or-bad. Since there are

no unambiguous criteria for deciding if the

problem is resolved, getting all stakeholders to

agree that a resolution is “good enough” can

be a challenge, but getting to a “good enough”

resolution may be the best we can do.

There is no immediate or ultimate test of a solution to a wicked problem. Since there is

no singular description of a wicked problem,

and since the very act of intervention has at

least the potential to change what we deem to

be “the problem,” there is no one way to test the

success of the proposed resolution.

Every implemented solution to a wicked problem has consequences. Solutions

CRACKING A WICKED PROBLEM

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a fitness goal, to lower insurance rates. “Our role is to provide

the tools and services and give credit when the member does

great things.”

In this sense, “It is very important that people are responsible

for the outcomes of their treatment,” says Le Goff. “We need to

hear their voice and understand their medical needs. They need

to be involved. If we can have a role in integrating the solution,

that is a role we can play.”

Dr. Glass agrees, noting that the most cost-effective treatments

are preventive and don’t involve traditional medical care.

“Twenty percent of the population still smokes. What can we

do to get them to stop? How do we help people with underlying

addiction issues? Better treatment of hypertension could bring

down the incidence of stroke, including limiting salt. We have

to think about incentivizing health interventions as one step

forward.”

What does a future-perfect picture of success look like? “It’s

when we’ve adapted our lifestyles and we say we can’t afford

to be obese,” says Dr. Glass. “We’re tracking ourselves to avoid

risks and consequences, because we think we have a future.”

to such problems generate waves of

consequences, and it’s impossible to know, in

advance and completely, how these waves will

eventually play out.

Wicked problems don’t have a well-described set of potential solutions. Various

stakeholders have differing views of acceptable

solutions. It’s a matter of judgment as to when

enough potential solutions have emerged and

which should be pursued.

Each wicked problem is essentially unique. There are no “classes” of solutions that can

be applied, a priori, to a specific case. Part

of the art of dealing with wicked problems is

not assuming any given solution is correct,

especially early in the investigation.

Each wicked problem can be considered a symptom of another problem. A wicked

problem is a set of interlocking issues and

constraints that change over time, embedded in

a dynamic social context. But, more importantly,

each proposed resolution of a particular

description of “a problem” should be expected to

generate its own set of unique problems.

The causes of a wicked problem can be explained in numerous ways. There are

many stakeholders who will have various

and changing ideas about what might be a

problem, what might be causing it, and how to

resolve it. There is no way to sort these different

explanations into sets of “correct/incorrect.”

The planner (designer) has no right to be wrong. Scientists are expected to formulate

hypotheses, which may or may not be

supportable by evidence. Designers don’t

have such a luxury — they’re expected to get

things right. People get hurt when planners

are “wrong.” Yet, there will always be some

condition under which planners will make errors.

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“INNOVATION IS ABOUT BUILDING A REVENUE CYCLE WHERE EACH TOUCH POINT ENHANCES THE PATIENT EXPERIENCE AND SHOWS ADDED VALUE.” - JENNIFER ZIMMER, INSIGNIAM PARTNER


01


INDISPENSABILITYMake the patient an offer, and give them an experience,

they can’t refuse.

BY ROBERT ITO

CONSUMER INDUSTRIES HAVE LONG KNOWN

the secret to capturing and retaining customers: offer the best

products and services for the price.

Anyone who has ever owned a luxury

vehicle no longer wants to live without

exceptional service, especially when

something goes wrong. To gain and keep

loyal customers, healthcare leaders would

do well to become equally indispensable

with patients, payers, and the community.

This means improving every aspect of

service, whether it’s in the primary

physician’s hospital, the specialist’s office,

or even the patient’s home.

“As a patient, healthcare can be very

daunting, so we’re finding ways to ease

their navigation, making sure that we

address what their expectations are,”

says William Dinsmoor, chief financial

officer of the Nebraska Medical Center,

a nationally ranked hospital in Omaha.

Technological innovation is key to that

mission; for example, the use of the

latest electronic medical record systems,

accessible along every step of the patient’s

medical journey, translates to speedier,

more efficient care. Similarly, technology

that tracks every aspect of a patient’s

care, from registration to outpatient

billing — like the Epic Systems suite of

healthcare software — can help identify

and eliminate medical redundancies, thus

driving down patient costs.

Healthcare organizations also need

to stake their claims as the go-to centers

for healthcare information, now more

than ever before. “As we experience changes in healthcare

systems, medicine is moving beyond the hospital’s four walls

and out to community settings, from

community-based organizations to tele-

health settings to retail health clinics,” says

Thomas Concannon, Ph.D., a policy

researcher at the RAND Corporation.

“Hospitals needs to be thinking about

taking the reins and trying to create and

sustain a place where stakeholders can

come together.”

Concannon believes that bidirectional

communication is essential, even if

many medical centers — academic and

research institutions, for example —

haven’t done much of it in the past. In

that spirit, creating transparency is the

obvious place to start, beginning with

clarity on pricing strategies, which today,

quite literally, are all over the map.

For instance, on average, the U.S.

spends twice as much on healthcare per

capita than other industrialized nations;

the same bypass surgery a citizen of

Switzerland receives for $17,000 will set

Americans back about $150,000. These

huge discrepancies have resulted in a

growth of so-called “medical tourism,”

where patients travel to places like

Belgium or South Korea to receive

operations at a fraction of the price that

they’d pay at home.

In this global environment, how do

American healthcare systems make

themselves competitive with their

international counterparts? How do they

BY THE NUMBERS

THE UNITED STATES HAS SIX TIMES MORE MRI MACHINES PER CAPITA THAN AUSTRALIA AND THE UNITED KINGDOM

6X

$150,000

$17,000

THE U.S. ALSO SPENDS AN AVERAGE OF TWICE AS MUCH ON HEALTHCARE PER CAPITA THAN OTHER INDUSTRIALIZED NATIONS.

AVERAGE COST OF A BYPASS SURGERY IN THE U.S. VERSUS SWITZERLAND

VS

prevent the people they serve from going to the other provider

down the block — let alone to the other provider overseas?

In other countries around the world, patients have ready

access to price lists for the procedures

offered at a hospital or clinic, a service

scarcely imaginable to most Americans.

“There’s been a lot of recent attention

to hospital pricing strategies in the

U.S.,” says Concannon. “These are

not transparent strategies. It would be

nice to see improved transparency in

inpatient stay, to see all the costs that

go into materials, labor, and residential

care.”

As more and more Americans learn

just how much less their overseas

counterparts have to pay for each

visit or procedure, there have been

increasing calls for change. A good

place to look is Canada, says Colin

Busby, senior policy analyst at the

C.D. Howe Institute, a Toronto-based think tank. There,

healthcare centers in some provinces are slowly moving from

a fee-for-service system to a more blended payment model. In

that model, family doctors are paid on a per-patient basis and

encouraged to enroll a large number of patients — basically,

the Accountable Care Organization

(ACO) model many physicians are

aiming for here. “By paying them per

patient, the incentive on a physician is to

only spend their time with their sickest

patients,” he says, “and to try to keep

everyone else healthy.”

In addition to lowering prices,

healthcare providers can also boost

their desirability by offering services

that their patients simply can’t receive

from their competition. “What we do

is provide a very high quality product,”

says Dinsmoor. “And we provide very

specialized services. We do things that

nobody else can.”

In the U.S., the drive toward more and

more advanced medical technologies is

another big reason for the country’s escalating healthcare

costs; for example, America has six times more magnetic


FINDING WAYS FOR DOCTORS TO SEE PATIENTS LESS — ALBEIT BY KEEPING THEM WELL — MIGHT BE THE BEST WAY TO INCREASE PATIENT SATISFACTION.

HEALTHCARE ORGANIZATIONS ALSO NEED TO STAKE THEIR CLAIMS AS THE GO-TO CENTERS FOR HEALTHCARE INFORMATION, NOW MORE THAN EVER BEFORE.

resonance imaging (MRI) machines per capita than Australia

and the United Kingdom.

But lest one think that Dinsmoor is just playing the medical

equipment arms race — “our proton therapy treatment program

is better than yours” — that’s just one part of the picture. Those

services Dinsmoor is talking about aren’t just hinged on having

the latest, greatest medical devices, although that’s certainly a

factor. The service component is part of a larger package of

customer relations.

Central to this is the understanding that physicians and

patients are all in this thing together. “Shared responsibility

is huge,” says Dr. Carlos Jaén, chair of the University of Texas

Health Science Center at San Antonio, Family & Community

Medicine. “We’re here to be partners. If you’re ready to do it,

I’m happy to help you. But it’s up to you, really. It’s your life.”

This idea of “shared responsibility” (both in terms of taking

care of one’s own health and paying one’s fair share for services)

is one that’s built into the systems of countries like France,

Belgium, and Japan.

When patients decide to become more proactive about their

healthcare, education and wellness centers will play a key role in

the future. “I think patient education is extremely important,” says

Dinsmoor, who cites the health management program Simply

Well as a step in the right direction. “It’s a tool that employers

can use to help screen and identify opportunities to improve their

employees’ health status,” he says. “If we want to bend the cost

curve in healthcare, we’ll need to shift resources from the back

end, from the complicated intervention, to more prevention.”

Ironically, finding ways for doctors to see patients less —

albeit by keeping them well — might be the best way to increase

patient satisfaction. Nobody likes being sick, after all, no matter

how efficient or professional the care at their hospital might

be. And while patient satisfaction might be a key component,

perhaps the most important component of making a healthcare

provider indispensable to its patients and payers, getting patients

to take responsibility for their own health, is often one of the

toughest things for doctors to do.

Although some regions of the world are further along than

others, forging stronger shared responsibility is a place where

the new U.S. model, driven by the Affordable Care Act, could

well stake a claim. “That’s the challenge with the ACA:

How are the individuals going to be engaged with this?” says

Dinsmoor. “What’s their responsibility? And that’s the piece

that’s been missing. The delivery system is getting organized

to do it, but how do you get the individual engaged? There are

some people that are very engaged with it, but there are lots

of people that are not. And underlying that is education, and

taking ownership of your own health status.”


01CRITICAL SUCCESS FACTOR

Indispensability: A healthcare system must make itself indispensable with an offering that healthcare community residents, patients, and payers cannot (and will not) avoid or go around.

CLOCKWISE FROM TOP LEFT: COLIN BUSBY, SENIOR POLICY ANALYST, C.D. HOWE INSTITUTE; THOMAS CONCANNON, PH.D., POLICY RESEARCHER, THE RAND CORPORATION; DR. CARLOS JAÉN, CHAIR, THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER, UT SAN ANTONIO; WILLIAM DINSMOOR, CFO, THE NEBRASKA MEDICAL CENTER.

HEALTHCARE LEADERS

TAKING CUES FROM THE HOSPITALITY INDUSTRY,

leading healthcare organizations around the globe have been

rethinking the experience they provide to patients.

The Beryl Institute, a global community of practice and

thought leaders, supports the notion that improving the patient

experience has financial implications that reach far beyond

reimbursement dollars, performance pay, and compensation tied

to outcomes. In a recently published white paper, “The State

of Patient Experience in American Hospitals 2013: Positive

Trends and Opportunities for the Future,” the Institute cites a

2008 J.D. Power study that revealed that

hospitals scoring in the top quartile in

satisfaction had more than two times the

margin of those at the bottom. Another

sobering fact is that a satisfied patient tells

three other people about the positive

experience while a dissatisfied patient

tells up to 25 people about a less-than-

satisfactory experience. Models suggest

that for every complaint the healthcare

organization hears, it could lose up to 18

patients, a clear threat to the bottom line.

“The patient experience is a top

priority for the Cleveland Clinic; it’s our North Star,” says

James Merlino, M.D., chief experience officer. “We’ve worked

diligently to create a strategy and supporting processes to help

us fulfill the patient-first philosophy. We align our people around

the patient service culture and that shapes how we manage

patient expectations.”

Merlino says Delos Cosgrove, M.D., Cleveland Clinic’s

president and CEO, set the expectations from the outset for

providing a world-class experience based on personal encounters

he and his family had with the healthcare system. “He realized


REINVENTING THE PATIENT EXPERIENCELet patient-centric care be your guide

BY TOM PECK

THE LOU RUVO CENTER FOR BRAIN HEALTH IN LAS VEGAS ONE

OF THE 22 SITES MANAGED BY THE CLEVELAND CLINIC NATIONWIDE.

02


that the entire experience is very important to the patient and

he was determined to put patients first in our organization.”

The patient experience thread is woven into every aspect of

the Cleveland Clinic’s culture. Merlino calls this managing the

360. “What patients think about us, how they get access to us,

their first impression — everything comprises their experience

with us,” he says.

Patient-centric care has turned healthcare on its head, causing

physicians, hospitals, and health systems to rethink how they

are treating their “customers”

and the long-term implications.

Jason Wolf, Ph.D., president

of The Beryl Institute, has seen

the evolution of the patient

experience. He says the patient

experience journey begins with

the integration of quality, safety,

and service.

“The patient and family don’t

delineate between these three

imperatives,” Wolf says. “They

need to be aligned around

components of healthcare

delivery. That’s why we define

the patient experience as the

sum of all interactions, shaped

by an organization’s culture that

influences patient perceptions

across the continuum of care.”

The Institute’s members have

tackled the patient experience

from a variety of angles, focusing

on specific opportunities to

improve the environment, care processes, communication,

and other aspects of the experience. One hospital in Ohio

reduced the noise level on patient units. Another addressed

parking hassles. A hospital in North Carolina implemented

bedside barcoding to make care delivery more efficient and

accurate. Another hospital in Minnesota focused on improving

physician and patient communications while a healthcare

organization in Florida created a blog from the CEO to connect

with staff, physicians, and the community. The list is endless

and demonstrates a nationwide commitment by healthcare

organizations to put patients first. Hospitals’ intentional efforts

to improve the patient experience are based on careful analysis

of their patient satisfaction data and their Hospital Consumer

Assessment of Healthcare Providers and Systems (HCAHPS)

survey scores.

Press Ganey, a leader in capturing patient satisfaction

and perception, establishes a link between profitability and

satisfaction in its 2012 white paper “Return on Investment:

Increasing Profitability by Improving Patient Satisfaction.” A

key finding cites a study of 82 hospitals where a 1 percent

standard deviation change in the quality score resulted in a

2 percent increase in operating margin. Another study of 51

hospitals found that approximately 30 percent of variance in

hospital profitability can be attributed to patient perceptions

of the quality of care. Finally,

another study estimated that

the financial implications of

moving all patients with average

Press Ganey ratings between

three and four to between four

and five was $2.3 million in

additional annual revenue.

The white paper highlights

hospital respondents’ top patient

experience priorities. The list is

comprised of mostly tactical

topics including reducing noise,

improving pain management,

enhancing the discharge process,

improving communication

among all stakeholders

(patients, staff, and physicians),

concentrating on cleanliness,

committing to hourly rounding,

and more.

Merlino and Wolf agree

that the investments healthcare

organizations make in

improving the patient experience will be repaid in the new

environment of population health management, where

coordination, communication, and collaboration are rewarded.

“Every encounter makes a difference across the continuum

of care,” explains Wolf. “All care delivery models are based

on one fundamental idea, the need to take care of patients

throughout their journey in the healthcare system. Creating

a truly great experience means concentrating on every aspect

of the experience. This includes hand-offs, communication

between staff, patients, and their families to technology, design

and functionality of space, and transitions from one care setting

to another.”

Recognizing the importance of patient and family

involvement in improvement efforts, the Cleveland Clinic

formed family councils that channel valuable feedback to the

THE INVESTMENTS HEALTHCARE ORGANIZATIONS MAKE IN IMPROVING THE PATIENT EXPERIENCE WILL BE REPAID IN THE NEW ENVIRONMENT OF POPULATION HEALTH MANAGEMENT, WHERE COORDINATION, COMMUNICATION, AND COLLABORATION ARE REWARDED.


organization. The Digestive Disease Institute is a perfect

example. Leaders were puzzled over low patient scores on

cleanliness. The council pointed to the bathrooms — an

important component of the patient experience in this area

— as the culprit. Poor organization and insufficient lighting

contributed to the perception that the bathrooms were dirty.

Shelves were added and lighting was improved. The result?

Patient satisfaction scores improved significantly.

Merlino relies on a number of sources to measure success,

including HCAHPS, which reflect the voice of patient

experience. Others include councils, focus groups with

former and current patients, and other anecdotal feedback.

“The entire management group reads letters and shares

patient stories with our staff at every opportunity,” says

Merlino. “We pay close attention to anecdotal comments,

both compliments and complaints, and distribute them

throughout the organization.”

The patient experience isn’t just an American

phenomenon, as evidenced by the work that the Cleveland

Clinic and The Beryl Institute are doing with international

partners. Wolf says the Institute has strong collaborative

relationships with the United Kingdom, South Africa,

Australia, and India.

He points to the Cleveland Clinic’s co-sponsorship of

PATIENT EXPERIENCE

BY THE NUMBERS

Amount a study of 51 hospitals found of variance

in hospital profitability that can be attributed to

patient perceptions of the quality of care.

$2.3 MILLION Another study estimated that the financial

implications of moving all patients with average

Press Ganey ratings between three and four

to between four and five was $2.3 million in

additional annual revenue.

The number of people a dissatisfied

patient tells about a less-than-

satisfactory experience versus the

three a satisfied patient tells about

a positive experience.25

Models suggest that

for every complaint the

healthcare organization

hears, it could be losing

up to 18 patients, a clear

threat to the bottom line. 1830%


02 CRITICAL SUCCESS FACTOR

Reinvent patient experience: Work with patients to re-engineer core patient processes to leverage technologies and drive dramatically better patient engagement and experience. There is a major distinction between understanding the role of the patient in healthcare and actually working with the patient to redesign patient care.

a leadership conference in Turkey for ministers of health in

emerging markets and its work with the United Arab Emirates,

as well as Dr. Cosgrove’s membership on the advisory committee

for the health minister of Saudi Arabia, and a future presentation

on empathy to healthcare leaders in the Netherlands.

As the patient experience movement gains momentum,

experts like Merlino will shape the profession. Wolf says

The Beryl Institute sees the C-suite of the future including

a new member — chief experience officer. Anthony

Cirillo, president of Fast Forward, a patient experience and

marketing firm, agrees. With the growing importance of

the HCAHPS results, having a senior executive at the table

concentrating specifically on the patient experience makes

sense. The chief experience officer plays a critical role in

operationalizing the concept of the patient experience

throughout the organization by being the champion for

employees and medical staff and providing resources to

help identify and realize improvement opportunities. The

Institute is developing a certification program and has

introduced a patient experience peer-reviewed journal to

support this effort.

“At the end of the day, no one organization holds the rights

to the patient experience — we all have to share and learn from

each other,” says Merlino. “After all, it’s the right thing to do.”


GETTING MORE FOR LESSIs your revenue cycle designed for the future?BY LIZ WILLDING

03

WHILE ADDRESSING REVENUE CYCLE ISSUES IN

healthcare varies from region to region around the world due

to different payer systems, one thing is for certain –– everyone

wants more for less.

“Fundamentally, the big question is, ‘How do we deliver

better healthcare outcomes with less healthcare dollars,’” says

Elizabeth H. Bradley, Ph.D., faculty director of the Yale Global

Health Institute. “The U.S. spends more than 17 percent of the

GDP on healthcare costs. This is one and a half times more

than any other country. The thing that executives struggle with

the most in any geography is how to influence the biggest

cost drivers, over which they may have very little control. In

particular, healthcare executives worry about how they can

impact wellness,” she says.

Dr. Bradley adds, “They can’t control the things that

contribute to poor health.”

Jennifer Zimmer, an Insigniam partner, says a large part of

the problem is that systems aren’t designed for the future, either

for treatment or preventive care. “Today’s systems, especially

in the U.S., are based on traditional, fee-for-service financial

models,” she says. “They are quickly becoming archaic and

need to be redesigned to serve a patient’s goals.”

Corinne Le Goff, president of Roche SAS, agrees,

especially as it relates to a growing trend toward innovations in

personalized medicine.

“Our system is set up for reimbursement of generalized


“OUR SYSTEM IS SET UP FOR REIMBURSEMENT OF GENERALIZED MEDICINE AND IS NOT DIFFERENTIATED FOR THE DISEASE STAGE.”-CORINNE LE GOFF, PRESIDENT OF ROCHE SAS

medicine and is not differentiated for the disease stage,” she

says. In oncology, for instance, she says advanced treatments may

combine different biologics based on the patient’s biomarkers.

“The system is not set up for that,” says Le Goff, who notes

that there are reimbursement pilot programs in place, but

questions whether actual information technology (IT) systems

are up to the task.

“When you talk to the government, it can be overwhelming

to say, ‘You have to totally redo your reimbursement system,’”

Le Goff says.

The ultimate answer, according to Zimmer, is redesigning

the revenue cycle. “While many models are being explored, it

essentially involves ‘establishing greater integrity or structural

soundness in the way you collect money,’” she says. “The

revenue cycle needs to be whole and intact for the realties of

healthcare in the future, and, oh, by the way, the future is rapidly

becoming now.”

Zimmer cites a recent example with U.S.-based Advanced

Homecare (AHC), a very large (Top 75) home care agency,

where their process was redesigned to make it easier for patients

to interact with the organization, so that multiple financial

touch points impact the patient just once.

“When we started in June, Advanced

Homecare had significant revenue

leakage, losing hundreds of thousands

per month on co-pays alone,” Zimmer

explains. Today the company is collecting

co-pays up front from patients, turning a

profit, and, in less than six months, is 80

percent to its fully captured goal.

“The employees, who are on the front

line with the patient, now understand

the impact their interactions about

payment have on the patient experience

and on the viability of the company.

And AHC is starting to see the money

come in. Their approach is the future

of healthcare and proof that you can

reinvent the process,” Zimmer says.

According to Joel Mills, CEO of

AHC, his organization was “stuck,”

essentially blaming a new computing

system for the organization’s financial issues.

“We were doing enough business to be successful, but not

getting the full potential from our hard work,” says Mills. “We

were stuck in not being able to bill for all the things we were

doing. We weren’t able to focus on the whole business.”

Mills adds that, “Reshaping our processes, and putting things

in the context of what’s best for the patient, turned things

around. It also helped our workforce and leaders to become

more engaged.”

Getting on top of coding issues is

another area where gains are to be made,

especially in the U.S., where healthcare

providers face sweeping changes when

new ICD-10 requirements go into

effect in October.

Mario A. Singleton, MBA/MHA,

who is the director of Hematology/

Oncology at Cone Health-Annie Penn

Cancer Center, made it his mission to

understand and address why revenue

wasn’t matching up with volume. Upon

doing a deep dive, he discovered that the

center was a couple of months behind

on billing, largely due to a coding

bottleneck.

“I didn’t think we had the proper

number of coders to keep up with the

volume and after implementing EPIC,

our new electronic medical record. After some discussions

with our oncology executive leadership team, we brought in

contract coders,” he explains. Singleton also did an audit on

recent patients and discovered that, in many cases, the system

was picking up the wrong J-codes.


“RESHAPING OUR PROCESSES, AND PUTTING THINGS IN THE CONTEXT OF WHAT’S BEST FOR THE PATIENT, TURNED THINGS AROUND. IT ALSO HELPED OUR WORKFORCE AND LEADERS TO BECOME MORE ENGAGED.”- JOE MILLS, CEO OF AHC

ROCHE HAS SEEN A GROWING TREND TOWARD INNOVATIONS IN PERSONALIZED MEDICINE — AND HAS ESTABLISHED PILOT

PROGRAMS TO ADDRESS EMERGING NEEDS AND ISSUES.


BY THE NUMBERSGETTING MORE FOR LESS

COUNTRIES WITH THE HIGHEST HEALTHCARE COSTS (AS PART OF GDP)

AMOUNT CONE HEALTH-ANNIE PENN

CANCER CENTER WENT FROM LOSING

TO GAINING, PER YEAR, AFTER

ADDRESSING CODING ISSUES.

11% 9.5%SWEDEN ENGLAND

$500,00003

CRITICAL SUCCESS FACTOR

New revenue cycle: Develop a highly effective, productive, and efficient (i.e., simplified) revenue cycle.

“I asked myself if we could get the coding done in five days,”

says Singleton. “How would that impact our finances? What if

the data was input correctly the first time? ”

When the issues were addressed, the Annie Penn Cancer

Center went from losing half a million per year to gaining as

much in two years’ time.

“One thing I found was that we needed a strong team lead to

oversee the coders and to make them understand their impact

on the revenue cycle,” Singleton says. “We needed to paint the

picture and let them realize their contributions to the team. We

put a strong team lead in place and when the coders discovered

that their role was vitally important, they became much more

invested in their work.”

Meanwhile, Singleton says his organization is gearing up for

the ICD-10 shift, with preparation including training and use

of a new electronic records management system that facilitates

tracking, both for the organization and patients.

“It is always disheartening and disconcerting when a patient

brings in a big binder documenting charges that are incorrect,”

he says. “With electronic health records, they can electronically

check their bills. It adds a lot of transparency.”

Singleton says he believes that better revenue cycle

management is a differentiator and will ultimately help address

other strategic issues, including wellness.

“When you are maximizing your revenue cycle management

with accuracy, efficiency, and cost-effectiveness, your organization

can realize the possibilities of caring for the patients,” says

Singleton. “Caring for each other, and the community, while

delivering measureable results in areas of quality, service, and cost

is something we strive to do daily. Before long, you really can

begin to see the possibilities.”

17%

UNITED STATES


DIVERSIFIED,YET INTEGRATED SPECIALIZATIONHow population health is putting the heart back into healing.BY ROBERT ITO

04

SHRINKING REIMBURSEMENTS AND INTENSE

cost cutting have left many physicians scratching their heads,

wondering why they got into medicine in the first place. Buried

under mountains of paperwork and feeling pulled in a million

directions, the impact of today’s changing healthcare landscape

has been a particularly harsh pill to swallow for those who are

at the heart of healing on any continent.

However, thanks to a global focus on population health,

which seeks to manage an individual’s health issues in a holistic

way, practitioners may yet have a fighting chance at returning to

their rightful place as healers. Restoring and sustaining health is

today’s mantra, versus just caring for patients when they fall ill.

One veritable force advocating for population health is America’s

Accountable Care Organization (ACO). A relatively new — and

controversial — departure from the traditional, volume-driven

fee-for-service model, the aim of ACOs is to create a system that

incentivizes practitioners to keep patients well.

Says Dr. Mike Weiss, chief medical officer at Optum Medical

Group, Southern California. “The biggest dysfunctional piece

of healthcare today is the reactive nature. Patients come to a

physician with a problem, they fix it, and move on. We need

to proactively reach out to patients of all populations, young

Incentivizing practitioners to be more proactive — as in

the case of diabetes care — is a way to shift care back to a

more holistic model.


and old.”

In this sense, he says the old saying, “An ounce of prevention

is worth a pound of cure,” has never been truer. However, he is

quick to add that executing is not without its challenges, which

he sees as two-fold. “First, physicians have to understand how

important it is to provide proactive care. Initially, it’s more work

because you have to look for ways to keep patients healthy.

Second, it is critical to engage the patient so they understand

the importance of their participation.”

Following a care protocol for diabetes is a good example.

“Diabetes doesn’t hurt and most people don’t even know they

have it until it is revealed,” Weiss says. “Our job is to intervene

before it hurts.”

Monarch took a novel approach when launching its top-

performing ACO several years ago,

initially developing the network with

its highest-performing physicians.

“Our Medicare Advantage physicians

already were coordinating care

very well,” explains Colin LeClair,

Monarch’s executive director. A

proprietary practice management

system was modeled after that used with

Medicare Advantage, putting valuable

information at the physicians’ fingertips

for fee-for-service patients.

“Previously the physicians had no

means of seeing data on these patients

unless they came in. Now they can see their MRIs, therapies,

etc. It gives the primary care physician more visibility into what’s

going on with the patients’ healthcare,” LeClair says. Just as

important, the ACO provides patients with a wide range of

services most aren’t even aware are available, like transportation

to appointments or to pick up medications.

So, in the ACO world, what exactly does preventive care

look like?

“The patient is compliant with his or her medication

regimen, fulfills required screenings, and is up-to-date on

scheduled screenings,” explains Dr. Weiss. “What we are looking

at is providing patients with all the information they need to

be successful.”

Along with happier, healthier patients, he says physician

satisfaction also improves. “Physicians want to do what’s best

for patients and the best way to do that is through access to

timely, accurate data. The data informs physicians so they can

provide better care. This, in turn, improves physician satisfaction

because their patients are doing better.”

If the population is kept healthy, the physician also benefits

financially, he explains. “In an ACO model, compensation is

based on quality. Instead of getting paid for more widgets, for

instance, we get paid for making higher-quality widgets.”

LATE TO THE GAMEAlthough a big shift for the United States, this approach is also

shared by the healthcare systems of European Organization for

Economic Co-operation and Development (OECD) countries

like the U.K., France, Germany, the Netherlands, and Sweden,

many of whom manage to do it in a much more efficient

manner — and nearly always at a much lower price.

There are currently 300 ACOs in the U.S. and counting, and

they have a lot in common with their international counterparts.

Recent healthcare legislation like Ontario’s Excellent Care for

All Act (2010) and England’s Health and

Social Care Bill (2011), share the ACO’s

focus on performance monitoring —

usually with increasingly more specific

means of monitoring improvement

in healthcare systems — and include

similar financial incentives to keep

patients from getting sick in the first

place.

There’s also been a shared focus

worldwide on how best to deal with

chronically ill patients –– that tiny 1

percent of utilizers who, according

to an oft-cited study by Rutgers

University economist Alan Monheit, account for nearly a third

of all healthcare spending in the U.S.

All of these programs seek to create more coordinated

and collaborative systems of care, with an integrated network

of doctors and specialists all working together to best serve

its population. In many ways, the U.S., with its historically

decentralized healthcare system, has a marked disadvantage to

this compared to its neighbors in Europe, with their single-payer

healthcare models. The infrastructure isn’t nearly as strong in the

U.S., let alone conducive to a collaborative mindset. How do you

get all those physicians to work together — particularly doctors

who, in the past, might not have tended to collaborate at all?

“You have to design systems by which the right thing to do is

also the easiest thing,” says Michael Ogden, M.D., chief clinical

integration officer at Cornerstone Healthcare, a medical group

with more than 90 locations in North Carolina. Cornerstone’s

recently acquired software tools allow doctors to identify their

community’s most at-risk patients.

It’s a trend that’s already well in place in New Zealand, a

country second only to Denmark in its use of electronic patient

300THE CURRENT NUMBER OF ACOS IN THE U.S.TODAY

records by primary care physicians (90 percent of the country’s

PCPs communicate online via secure networks). Additionally,

95 percent of New Zealanders are registered in the National

Health Index, an integrated system that allows hospitals and

health agencies to share information anywhere in the country.

Once high-risk patients at Cornerstone are identified,

says Ogden, they’re directed to centers like Cornerstone’s

Personalized Life Care Clinic, a specialized, coordinated care

center that focuses on the top 3 to 5 percent of the group’s

neediest patients. “They have a navigator, someone who can

coordinate care between different specialists,” he says. “We have

a dietician, a pharmacist, and access to psychology all clustered

within a life care clinic.”

WELCOME TO THE NEIGHBORHOODOne of the most recent experiments in clinically integrated

networks is the Patient Centered Medical Neighborhood

(PCMN), a healthcare model that expands on the concept of

the Patient Centered Medical Home. In 2012, Kansas-based

TransforMED received a $21 million, three-year grant from

the Centers for Medicare and Medicaid Innovation (CMMI)

to create Medical Neighborhoods in 15 communities around

the country.

By definition, the medical neighborhood concept

encompasses everything from wellness to complex care, with

coordination originating through the primary care practice and

extending to hospital systems, medical specialties, and other

community health services to support a fully integrated care

approach.

For example, TransforMED CEO Bruce Bagley, M.D.,

foresees a day when a woman can see her family physician about

a breast lump at 10 in the morning, get a mammogram at 11,

and talk with someone about the results at 1. “By the time she

goes home for dinner, she’s had a biopsy and gotten the results,

and is holding in her hand a CD-ROM of a decision aid that

can help her understand her choices and options in an unbiased

way,” he says. “That’s clinical integration.”

For ACOs, integration can apply to something as narrow

as one-on-one, doctor-to-doctor communication, or to

something as broad as previously competing healthcare

providers sharing patient records. “If you have a community

that has three hospital systems, historically those three systems

haven’t worked together very well,” says Russell W. Kohl, M.D.,

medical director at TransforMED’s Innovation for Centers of

Excellence, who is currently spearheading the group’s PCMN

project. “They’ve been focused on trying to control market


Countries such as the U.K., France, Germany, the Netherlands, and Sweden have long utilized benefits of an ACO-type healthcare structure.



Diversified, yet integrated specialization: Optimize physician network with strong physician leadership, collaboration, diversity of specialization, and alignment.

Amount chronically ill patients account for of all healthcare

spending in the U.S. These patients only make up 1 percent of utilizers.

1/3

$13 MILLIONAmount Pioneer ACO at Banner Health Network in Arizona netted in shared savings in its first year of existence.

30%

95%Number of New Zealand citizens registered in the National Health Index, an integrated system that allows hospitals and health agencies to share information anywhere in the country.

SPECIALIZATION BY THE NUMBERS

Percentage of current healthcare spending that is duplicative and wasteful.

share, so in areas where you have limited specialist availability, that can

certainly be an issue,” says Kohl.

A possible solution: getting these former foes to realize the cost-

cutting value of shared services. “ACOs need to look at things like, ‘Do

we really need to have five cardiac catheterization labs within one mile

of each other in the city of Boston,’” says Thomas Concannon, Ph.D.,

a policy researcher at the RAND Corporation. “They need to look at

the mechanisms they could use to coordinate service and technology.”

It’s that sort of coordination, say the proponents of ACOs, that’s key

to driving down healthcare costs. According to the Dartmouth Atlas of

Healthcare, an ongoing project under the auspices of the Dartmouth

Institute for Health Policy and Clinical Practice, up to 30 percent of

current healthcare spending is duplicative and wasteful. One of the

primary missions of the ACO is to reduce that waste, with the shared

savings being distributed between CMS and the participating ACO.

Those shared savings are the carrot, but many healthcare systems

overseas also utilize a pretty big stick. One example: Under their

diagnosis-related groups (DRG) system, hospitals in most European

countries won’t receive a second payment if a patient has to be

readmitted for the same medical issue within 30 days.

In its first year of existence, the Pioneer ACO at Banner Health

Network in Arizona netted $13.3 million in shared savings. One of its

most successful programs involves an algorithm that identifies its most

high-risk patients before they’re rolled into the ER (among the triggers

are patients who are on more than seven medications a year). In some

cases, R.N.s are dispatched right into providers’ offices and patients’

homes. But it’s the sort of integration of services that’s helping to drive

Banner’s health costs ever downward.

“There’s been a learning curve for our providers,” admits Matt Horn,

director of Banner Health’s Pioneer ACO. “Providers haven’t always

been willing to allow another care provider to come into their office

who hasn’t historically been there,” says Horn. “But the beneficiaries

appreciate it. They appreciate having that extra person there.”


MINDSET OF WELL-BEINGShifting the focus is all about engagementBY LIZ WILLDING

05

TO PULL OFF POPULATION HEALTH, NO MATTER

your geography, everyone in the continuum — executives,

physicians, the clinical support staff, administrative workers, and

ultimately the patient — must be locked on one central goal:

well-being. This mindset is a quantum shift from providing care

primarily when an illness presents itself. It starts by engaging

every individual in the healthcare workforce on how their

part of the process impacts patients and ultimately extends to

fostering healthy lifestyle changes by patients themselves.

What will it take for everyone in a healthcare organization

to understand their impact on patients? It begins by showing

everyone in the healthcare delivery process how their role

impacts patients, especially by their actions or inactions, says

Jordan Safirstein, M.D., a cardiologist and member of the

Google Healthcare Advisory Board, and assistant director

of the Cardiac Catheterization Laboratories at the Gagnon

Cardiovascular Institute, Morristown Medical Center. Dr.

Safirstein gave an example of how this can impact the life —

or death — of patients requiring an emergency catheterization

procedure.

“It is important to show the emergency management

system (EMS) crews and the first responders how they can

affect door-to-balloon times if they do not meet certain time

points, and the emergency room staff is crucial to expediting

the patient once they arrive in the ER,” says Safirstein. “Then

the cath lab receiving staff is essential to rapid prepping and

troubleshooting, even before the physician steps into the room.

Safirstein continues,“Finally, there’s the role the doctor plays

in the technical achievement of timely success. All of these time

points and goals are reviewed monthly and consistent sore spots

are remedied with changes in protocols. It is an ever-improving

process, like healthcare itself, as technologies and paradigms

change. The strategy is to get people to understand their roles,

make sure they see the results on the end product, and to be

accountable by making those results visible to the rest of the

team.”

While the impact on well-being is most dramatically

illustrated in an emergency situation, it is important for everyone

in the continuum of care to understand the importance of their

job and its impact on the patient, from physicians and nurses

to the administrative staff. Healthcare executives might assume

that all the players are sensitized to the patient impact, but, says

Jennifer Zimmer, Insigniam partner, this isn’t always the case.

Making such false assumptions is a huge barrier in the

workplace, she explains. “This behavior does not create

innovative or breakthrough results. It’s business as usual.”

GOING BEYOND TREATMENT TO LIFESTYLE

While the healthcare industry traditionally defines the

“continuum” as actions taken to address a patient’s particular

disease state, addressing lifestyle issues is no less important when

it comes to preventing or slowing the progression of disease.

Again, engagement is key, especially in the workplace, directly

reaching patients with interventions that motivate healthy

behaviors.

Based on research conducted by Gallup in 2012, engaged

employees are more likely to report a healthier lifestyle than

their unhealthy counterparts, and they are less likely to be obese

or have chronic diseases. Although obesity, as a general category,

is hard to quantify, one study, published by the Harvard School

of Public Health in 2012, estimated that 21 percent of the total

U.S. spending on healthcare was devoted to obesity related

issues.

Insurance providers and the private sector are jumping into

the game, providing tools and incentives to encourage lifestyle

changes. “We’ve done a good job reaching people who are

inclined toward a healthy lifestyle,” explains Joan Kennedy,

Cigna vice president, customer health engagement. However,

she acknowledges that these people aren’t in the majority.

A universal problem, Kennedy notes, is that countries such

as China are equally befuddled about how to motivate their

society on wellness, which is facing a growing epidemic of

obesity and diabetes. China’s woes are largely due to an increase

in sedentary jobs as the country becomes more industrialized,

as well as adoption of a more westernized diet.

PRESCRIBING A DOSE OF EMPATHY

Reaching at-risk individuals revolves around empathy, says

Alexandra Drane, founder and president of Eliza Corporation,

which provides health engagement management solutions.

Teaming with the Altarum Institute, a healthcare research

organization, they surveyed more than 30,000 individuals and

found, overwhelmingly, that life obstacles often made it too

difficult for people to make health a priority.

“Life obstacles like caregiving, financial, and relationship

stress were cited as key factors throwing life out of balance,”

Drane explains, adding that unless healthcare organizations help

people address these stressors, which she calls “unmentionables,”

their wellness efforts are likely to fall on deaf ears.

This is why programs traditionally focused on disease states

have been met with low enthusiasm, she says. Simply put,

messaging that lectures people about what they aren’t doing,

hasn’t worked well for the broader population.

“People have told us that they simply don’t have time to

focus on their weight, for instance, because they are too stressed

out caring for an elderly parent. When we listened, and we

offer information on resources, nearly all of those surveyed

sought help.”

Building on the research, Eliza developed a tool called the

Vulnerability Index that helps health organizations quantify

the prevalence and impact of contextual life factors, which are

influenced by negative and positive coping responses.

Believing in the directional vision of this approach has

helped Cigna rethink its messaging, Kennedy explains. “We

asked ourselves, is there a way to re-architect our approach to

wellness, putting the pressing issues first? We found that once

you get the larger stressors calmed, you have a better chance of

addressing a person’s underlying health issues.”

Today, Cigna is in the midst of a pilot, which, based on

vulnerability, leads to different types of interventions. “We are

architecting incentives and interventions to tie to the whole

person, instead of using a fragmented approach,” Kennedy says.

Part of the solution involves tying Cigna coaches with members

and their physicians, both receiving rewards for improvement.

The approach is also driving better use of employee

assistance programs, or EAPs, which have become stigmatized

for singling out individuals seeking emotional help. “We

encourage organizations to reinvent EAPs so people feel

comfortable turning to them as a resource.”

How well is this kinder, gentler approach working?

“We are getting good participation in our pilot,” Kennedy

says; however, she is cautiously optimistic, adding that “none

of us know the answer, because we’ve never tried this before.”

THE IMPACT OF TECHNOLOGY

The use of mobile technology is also emerging as an

important enabler, with apps and fitness devices helping

individuals monitor their progress. “There are more than

40,000 health and wellness apps currently in the marketplace,

which is a bit overwhelming,” Kennedy explains. “We have a

team of experts who are evaluating and recommending some

for our online ‘Go You’ marketplace.” Go You, a Cigna portal,

allows members to access tools and services that monitor their

wellness activities.

She notes that use of apps especially makes sense in countries

where the population is highly mobile.

“In South Korea, for instance, people are entirely mobile and

you have to reach them through their phone. In other regions

of the world, you may have to work around the healthcare

architecture.”

The main point, says Kennedy, is to give support in ways that

people want to receive it — and in a way that shows you care.



Mindset of well-being: Create a mindset for patient care that looks from a broad view of the overall patient’s health and well-being across a continuum of care.


06

IN 2015, WOMEN’S COLLEGE HOSPITAL IN TORONTO, CANADA, WILL RELOCATE TO A STATE-OF-THE ART FACILITY (PICTURED) THAT COMPLEMENTS THEIR VISIONARY APPROACH TO HEALTHCARE.


WHAT HAPPENS WHEN YOU MAKE A 180 DEGREE

shift in your business model, moving from acute care to

an ambulatory care model? Women’s College Hospital

in Toronto, Ontario, Canada, did just that, challenging

traditional thinking at all levels of its organization about

healthcare delivery. An inpatient acute-care hospital with

130 years of service, this radical shift was precipitated by a

pre-arranged merger with two other healthcare institutions

in 1998. Eight years later, administrators successfully

negotiated with the government of Ontario to once again

be a stand-alone organization.

“Part of the price that we paid for independence was a

stipulation from the government of Ontario that we could

operate only as an ambulatory facility,” says Marilyn Emery,

president and chief executive officer of Women’s College

Hospital. “We could have chosen to go down the mainstream

route, but we chose instead to take a visionary approach, one

more suited to where we felt healthcare is headed. While we

continue to focus on advancing healthcare for women, we

are aggressively addressing the transitions between acute-

care and post-acute care.”

Why has Women’s College Hospital thrived in its pursuit

of outpatient excellence? How has it succeeded when

others are struggling? What does the future look like for

the organization?

Emery credits a comprehensive 2½ year strategic planning

process guided by the hospital’s mission as the foundation

upon which all programming has been built. The process

was driven by the need to answer two questions — who

is Women’s College Hospital and what did it provide

to the community? The honest conversations that took

place among key stakeholders, including board members,

physicians, staff, and the community, provided a bridge

between women’s healthcare and ambulatory care. A key

driver was the provincial government’s interest in shifting

people from inpatient care, the most expensive type of care,

to outpatient care through innovation that could ultimately

result in people never being hospitalized in the first place.

The strategic roadmap that emerged defined a clear vision

and focused on identifying gaps and developing innovative

services, not duplicating existing services.

To achieve its mission, the organization identified three

NEW HORIZONS A model for the future of healthcare: Women’s College Hospital

BY TOM PECK

THE HOSPITAL DEFINES ITS VISION AS BEING, “CANADA’S LEADING ACADEMIC, AMBULATORY HOSPITAL AND A WORLD LEADER IN WOMEN’S HEALTH.”


specific areas of focus: health for women, health system

solutions, and complex chronic conditions. These are

supported by six innovation streams: driving systematic

solutions in healthcare for women,

preventing acute care admission

and readmission, enabling superior

coordinated care, transforming

inpatient care models to outpatient

care, enabling system integration

and care transitions, and building

a virtual hospital. Three corporate

directives guide the hospital’s

decision-making and action

planning: drive the innovation

agenda, strengthen the capacity to

lead from its mandate, and grow its

academic impact.

Emery says the senior team talks

about the corporate directives

daily. “It really is the culture of

the organization. The directives

enable close integration between

research, clinical care and everything else that goes on in

the organization,” she says.

Women’s College Hospital has been deliberate about

designing outpatient programs to serve marginalized and

underserved patients — a gap identified in its strategic

plan. An example is the Toronto Birthing Center, a

midwife run program located in

a free-standing facility in a high-

needs neighborhood. The center

is designed to improve access for a

variety of frequently underserved

groups, including Abor iginal

women, immigrant women, inner

city women, women who identify

as LGBTQ, refugees, teens, and the

noninsured.

The hospital operates in an

undefined space in healthcare, so it

is difficult for people to grasp what

it does. It is used as an incubator for

the rest of Canada’s health system.

The work it is doing has grabbed

the attention of health leaders across

Canada and around the world.

“We are often contacted by other

organizations interested in learning who we are, what we

do, and how we do it,” says Emery. “We just hosted a group

from Vietnam and our physicians and scientists are frequent

“WE CAN’T FALL BACK ON INPATIENT BEDS, SO THAT’S CREATED A TREMENDOUS OPPORTUNITY FOR INNOVATION.” - MARILYN EMERY, CEO AND PRESIDENT, WOMEN’S COLLEGE HOSPITAL

speakers on the international scene. We’ve adapted concepts

such as the virtual ward from the United Kingdom. A

U.K. delegation visited our organization, studied the

improvements we had made, and took our ideas back with

them.”

Partnering with other healthcare providers and

government agencies has been vital to Women’s College

Hospital’s success. “We need the ability to refer patients

to inpatient facilities,” says Emery. “When you’re looking

to solve problems that are difficult for everyone, you need

multiple perspectives and resources. We constantly ask other

providers what we can do to help them meet the challenges

and resolve the problems they are facing.”

Heather McPherson, Women’s College Hospital’s

executive vice president of patient care and ambulatory

innovation, says data related to patients’ expectation of

ambulatory care has helped align physicians and staff with

the hospital’s mission and strategic plan. Patients expect

to wait around 20 minutes for service in an outpatient

care setting. Benchmarking the organization’s actual

performance against these expectations, as well as against

the performance of peer organizations and incorporating

patient feedback on their experience, has provided evidence

to help the hospital improve.

“We can’t fall back on inpatient beds, so that’s created a

tremendous opportunity for innovation,” explains Emery.

“We have one of the biggest breast reconstruction surgical

programs in Ontario. The average length of stay for this

procedure is five to six days. Our interdisciplinary teams

spent one year developing a care pathway that created higher

quality care, increased patient satisfaction, and reduced the

amount of time at the hospital to 18 hours.”

By adopting systematic innovations across their business

model, Women’s College Hospital is a living embodiment

of what’s on the horizon for the healthcare industry.



New horizons: Expand patient care beyond physician-centered and acute-hospital-located care delivery.

BY FOCUSING ON INCREASED PATIENT SATISFACTION, WOMEN’S COLLEGE HOSPITAL DEVELOPED A PATHWAY TO INTERDISCIPLINARY IMPROVEMENT.


HEALTHCARE LEADERS, OUR TIME IS NOW“Innovation” is today’s critical objective.BY LIZ WILLDING

07

WITH SO MANY DRAMATIC SHIFTS HAPPENING

across the healthcare landscape, now is the time for innovation.

Business as usual will no longer suffice, whether it’s coping

with an aging population fraught with noncommunicable

diseases or shifting to a focus on wellness.

“This is our moment in time to transform healthcare,” says

Nathan Owen Rosenberg, Insigniam founding partner. “It is

time for healthcare leaders to define and realize a new, bold

future for the care and health of our population.”

Globally, a host of forward-thinking organizations already

have read the tea leaves, actively innovating demonstrations

into what global healthcare will look like in the future. At the

Mayo Clinic, for instance, approximately 65 people are actively

dedicated to identifying and testing new ideas, using human-

centered design methods.

“Our approach is to transform the way people experience

healthcare,” explains Douglas L. Wood, M.D., who is the director

of the Center for Innovation at Mayo Clinic. Emphasizing

that “we are fundamentally interested in putting the needs of

people first,” he references research that identifies key reasons

why people often don’t seek care due to barriers created by

providers and the system.

“We listen to people’s needs, and we often try to force them

into care, blaming them if they are noncompliant. People also

spend most of their time out of clinics; we need to develop

and deliver care where they are, instead

of forcing them to go to clinics where

they may not feel comfortable.”

Dr. Wood adds that “we have lots

of roles for sickness care, but not a lot

for health. Our systems force protocols

on people that are rigid and not very

helpful.”

Types of innovation projects coming

out of Mayo Clinic’s Center for

Innovation range from changing the

delivery of care for expectant mothers

–– even equipping them with Doppler

ultrasound machines so they can

listen to their babies — to creating a

laboratory in an assisted-living facility to

manage transitions from hospital to home settings, and even

embedding “designers” who are studying ways to mitigate the

stresses of campus life into the campus environment at Arizona

State University.

Similarly, integrated care consortium, Kaiser Permanente,

operates its “Hospital of the Future”

project, creating scale models of an

integrated system linking doctors

and clinics, as well as a health

insurance component, all housed

inside its 37,000-square-foot Garfield

Innovation Center in San Leandro,

California.

Cross the ocean to China and there’s

the “Innovation City” on the outskirts

of Wuhan, the country’s newest symbol

of the government’s mandate for

innovation. Complete with two dozen

structures, it was no more than rolling

farmland just two years ago.

The European Union has also

embraced the concept of innovation, establishing the

“Innovation Union – A European 2020 Initiative.” One of


“IT IS TIME FOR HEALTHCARE LEADERS TO DEFINE AND REALIZE A NEW, BOLD FUTURE FOR THE CARE AND HEALTH OF OUR POPULATION.” - NATHAN OWEN ROSENBERG, INSIGNIAM CO-FOUNDING PARTNER


LEADERSHIP MANDATE

PROPRIETARYPROCESSES

INSIGNIAM’S FOUR PILLARS FOR INNOVATION

its goals is to create a single European research area to attract

science and technology talent and funding as a means to

compete with U.S. and Asian markets.

In Switzerland, heavy emphasis also is being placed on

innovating business processes, with a new hospital financing

system, launched in 2012, addressing access to capital and

encouraging competition and consolidation. This program is

focused not only on efficiency, but also on care and quality.

CREATE VALUEAt the end of the day, “Innovation is about delivering new

value,” says Nathan Owen Rosenberg, Insigniam co-founder,

noting that there are “huge challenges in the delivery of

services.”

Indeed, says Rosenberg, who believes the only way to survive

in today’s volatile environment is to innovate with a focus on

accountability. The simple truth, he says, is that patients, as they

become more accountable for their care, “are going to be

shopping,” which creates a new layer of competition.

Robert E. Johnston, Insigniam consultant and co-author

with J. Douglas Bate of The Power of Strategy Innovation, agrees.

Since publishing in 2003, he says he has observed global

healthcare innovation mature to a place outside of research and

development.

“We are now moving from ad hoc to breakthrough,

quantum innovation,” he explains. “That is the new high bar.”

To innovate effectively requires a very deliberate and

organized effort, he explains, with Insigniam’s approach based

on four pillars for innovation:

1. Leadership mandate

2. Dedicated infrastructure

3. Proprietary processes

4. Supportive culture

“First, the C-Suite must send a very loud and clear mandate

for innovation across the enterprise that is relevant to all

employees,” Johnston says. “They also must give the necessary

permission to do fresh thinking, and they must back this up

with funding, people, time, and space.”

Johnston says that the creation of innovation labs on the scale

of Mayo and Kaiser Permamente is becoming an increasingly

common phenomenon; however, it is possible to scale up in a

less grandiose way.

“One way to jump-start embedded innovation in the DNA

of an organization is to commit to a yearlong innovation

immersion,” he explains. “Once you have a vision for your

future organization, you plan backwards. This way you

eliminate all the noise that over time becomes irrelevant.”

The metaphor he says he uses the most these days is that

“every organization is on its own innovation journey. You have

to get from point A to point B.”

Working with an organization in

South Africa, Johnston describes an

innovation immersion experience

that began with two executive teams.

In short order, they chartered 26

additional innovation, or I-Teams, to

address both tactical and strategic issues.

After the initial launch, a mid-year

“jam session” was held, and the energy

and enthusiasm level was “palatable,”

he says. By the end of the year, which

wrapped up with a celebration, many

of the teams had completed their work,

resulting in pipelines of new business

opportunities and significant cost-

saving opportunities.

For this company, what began as a

one-year effort is now in the third year

of its journey.

While attending a recent conference hosted by the

Massachusetts Institute of Technology (MIT), Johnston

recalls watching “Hack-a-Thons,” which involve participants

“hacking their way through how clinical trials are conducted

today.”

“It’s difficult to enroll patients and even tougher to keep

them in the program,” says Johnston. “The idea was to attract

and keep patients in for the long haul by offering them, up

front, free drug therapy, pending approval by the Food and

Drug Administration (FDA).”

MIT has staged 10 of its “Hack-a-Thons” around the world

in hospital organizations, and out of these have come 10 new

ventures that are receiving third-party funding.

BEWARE THE BARRIERSHowever, while innovation can breathe new life into an

organization, there are barriers that can derail even the best

efforts.

Rosenberg says executives should also be aware of their

“corporate immune system,” which repels ideas because

“that wouldn’t happen here” and “senior management will

never go for that.” Equally debilitating is corporate myopia,

where organizations “have a very narrow lens for how they

define business,” and corporate gravity, which holds down

organizations that operate under a “can’t-do mindset.”

Ultimately, innovation is only as good as its execution.

Insigniam conducted an Executive Sentiment survey in 2013,

asking 200 executives how prepared they are to innovate

and execute on their innovation ideas. An overwhelming

87 percent said innovation is the

most important or a very important

factor in their organizations’ ability

to succeed and strengthen their

competitive advantage in the next

12 to 13 months. However, only 15

percent felt their organizations were

well prepared to generate the needed

level of innovation.

“Many of today’s health leaders

are in shock by all the changes facing

healthcare,” Johnston says. “They

are catatonic. I’ve heard leaders say,

‘When we look into the future, we

don’t know what is going to happen.

It is like we’re walking into a dark

room.’

“Well, at some point, the lights are

going to come on. The organizations that are most prepared

to handle the opportunities will win … and the others will be

left behind.”

He adds that while it is entirely impossible to predict what

the future will hold, “you don’t want to be surprised by it

either. You can’t predict, but you can influence,” which is what

innovation, at its core, is all about.



Embedded innovation: Embed in the organization a competency for creativity to continually innovate and rapidly execute innovation and change.

“WE NEED TO DEVELOP AND DELIVER CARE WHERE THEY ARE, INSTEAD OF FORCING THEM TO GO TO CLINICS WHERE THEY MAY NOT FEEL COMFORTABLE.” - DR. DOUGLAS L. WOOD, DIRECTOR OF THE CENTER FOR INNOVATION, MAYO CLINIC

IT IS AN INDISPUTABLE FACT THAT INFORMATION

technology is revolutionizing healthcare. An explosion

of mobile applications (mHealth) is enabling patients to

use their smartphones to monitor their chronic conditions

and connect with their physicians. Blood pressure, cardiac

monitoring, and blood glucose monitoring are early entrants

in the world of mHealth. As an enabler, IT is helping to

care for patients in their home versus the hospital, providing

real-time information that physicians can monitor and react

to immediately.

The implications are fantastic and seemingly once relegated

to the world of science fiction. For instance, Proteus, a digital

health company, recently received FDA approval to manufacture

pills with edible electronic sensors. An online

mHealth app receives data transmitted by the

sensors, enabling physicians to track a patient’s

medication compliance. This technology

addresses the costly problem of medication

noncompliance, estimated to cost the U.S.

healthcare system alone as much as $290

billion.

A report published by research2guidance predicts that by

2017, the mHealth market will reach billions of people around

the globe via their smartphones and tablets. Research and

Markets, an international market research firm, estimates

the current value of the global mHealth apps market at $6.6

billion, growing to $20.7 billion by 2018. The mHealth apps

market in the United States was estimated to be valued at $2.9

billion in 2013.

The report predicts the highest growth will occur in diabetes

management devices due to the increasing global burden of the

disease. The proliferation of apps related to diabetes validates the

prediction. OnTrack for Android smartphones allows diabetics

to track blood glucose highs and lows, food intake, medications,


LEVERAGING NEW TECHNOLOGYTake technology to a personal levelBY TOM PECK

08

blood pressure, pulse, exercise, and weight all in one place.

SiDiary captures, stores, and analyzes relevant data for use in

diabetic therapy. The Diabetes Diet app contains hundreds of

healthy recipes. A recent clinical trial conducted by WellDoc

demonstrated that combining patient behavioral coaching via

mobile applications with blood glucose data, lifestyle behaviors,

and patient self-management data substantially reduces glycated

hemoglobin levels over one year.

The Food and Drug Administration projects that the mobile

app market will grow by 25 percent annually for the near future,

with companies investing record amounts in developing new

health apps. Consumers will find more and more options from

which to choose. There are more than 40,000 health apps

currently on iTunes, including calorie counters, prescription

reminders, and physician and hospital locators.

As of September 2013, the FDA had cleared nearly 100

mobile medical apps including blood pressure monitors, apps

that send real-time readings of electrocardiographs to physicians,

and apps that access vital signs for use in emergency cardiac care.

“Mobile apps are unleashing amazing creativity, and we

intend to encourage these exciting innovations,” says Bakul

Patel, M.S., MBA, senior policy advisor to the director of FDA’s

Center for Devices and Radiological Health. “At the same time,

we have set risk-based priorities and are focusing the FDA’s

oversight on mobile apps that are devices for which safety and

effectiveness are critical.”

Physicians also are embracing mobile technology via their

tablets to access a variety of data including EMR information

and drug reference facts. A 2012 survey by InformationWeek

asked IT teams which mobile computing devices physicians in

their organization were using for medical purposes, and more

than two-thirds, 66 percent, reported iPads or other tablets — a

21 percent increase in just 12 months.

The expansion of mHealth also promises to address a looming

physician shortage by enabling physicians to monitor large

numbers of patients remotely, respond to their questions quickly,

and make better, more informed decisions about their care.

In a recent TED Talk, Eric Dishman, director of proactive

health research at Intel Corporation, said the current healthcare

system “must change,” and it’s up to individuals to wake up

and take control of their health. Dishman’s vision is one where

patients will no longer be tethered to a central location for care.

They will be able to take an active role in their own well-being.

Information technology will facilitate care coordination among

a team of caregivers, eliminating the all-too-common practice

of disparate specialists prescribing duplicative or contraindicated

drugs to patients, often resulting in costly hospital admissions.

“Information technology has moved from a position of

dread to a position of desire,”

says David Muntz, former

principal deputy director of

the Office of the National

Coordinator on Health

Information Technology.

“Healthcare really wants

technology now, and I see

that as a real sea change,” he

says. “The government has

been using a stimulus program

effectively in combination

with policy to encourage

healthcare organizations

to adopt technologies that

are interoperable. This will

revolutionize healthcare

because it will enable people

to go where they want to go, without duplication, and they

will be able to access all points along the continuum of care.”

Dishman also advocates using information technology to

accelerate care customization. The ability to map individuals’

entire genetic makeup will allow healthcare providers to

build specific predictive models that will eliminate the costly

guesswork that often plagues today’s system and replace it with

targeted therapies that will improve effectiveness and reduce

costs.

Muntz seems to concur, adding “Information technology is

unlike any other resource available in healthcare. It allows you to

hardwire processes that you can’t control and assure outcomes,”

he says. “Health information technology helps create better

avenues and opportunities for communication, coordination,

and collaboration.



Leveraging new technology: Establish a strong capability and capacity to leverage information technology, including but not limited to mobile and web technology.

BILLION

$2.9THE MHEALTH APPS MARKET ESTIMATED

VALUE IN 2013.

AS THE HEALTHCARE INDUSTRY EMBARKS ON

reinventing itself, going about the hard work of transforming

managers into leaders truly is a critical success factor. However,

does an industry that is currently stymied by outdated

hierarchical management structures, functional silos, and

cultures based on rewarding activity versus outcomes have the

institutional fortitude to step up and invest in “making” leaders

who can redefine the future? If so, where will the next wave of

leaders come from? As the industry moves toward population

health, how will physician leaders factor into the equation?

Executives at Cone Health, a successful, six-hospital

healthcare system in North Carolina with approximately 10,000

employees, have asked all

of these questions and

more. In a process that

began by envisioning

the future, they set out

several years ago to

define new goals and

values. At the behest of

R. Timothy Rice, Cone

Health’s CEO, they set

the “audacious goal” to rank in the top decile nationally on

all major quality measures by 2015, realizing, of course, that a

“business as usual” management style no longer would suffice.

“We needed a highly motivated and empowered team that

consistently put patients and their needs first,” explains Joan

Evans, Cone Health’s vice president, organizational effectiveness

and performance. “Our managers had to make the shift to

being leaders for the future. They had to learn how to ask hard

questions, including, ‘What’s the value? How do we measure

it? Who is going to be accountable?’ We had to teach them

how to do that.”

With the shift to population health, it also became clear that


TRANSFORMATIONAL LEADERSHIPFor Cone Health, “unleashing the tiger” of transformation begins with empowerment.BY NATHAN OWEN ROSENBERG

09


more physician leaders would be needed. Since many lacked

the necessary collaboration skills for group decision-making, a

dedicated training program was required.

SHIFTING FROM MANAGERS TO LEADERSCone’s first step began with an increased focus on

communication skills. “Because

system thinking is critical, moving

from hospital to population

health, our leaders now had to

think upstream and downstream,”

Evans explains. “What’s happened

before to the patient? What’s

happening after we care for

them? To be mindful of the voice

of the customer, they needed to

learn how to be fully present

with patients and employees,

developing deep listening skills.”

From there, the focus expanded

to culture, working with leaders

to help them inspire and motivate the employee base. “We

needed a leadership team who could talk about

what mattered most in a new way and who were

able to generate action to inform our new future,”

Evans says. “To do this, we had to learn how

to unhook from the past, invent the future, and

engage employees.”

Although it may sound simplistic, Evans says

a key realization for leaders and employees alike

was that “the transformation starts with you. It’s

a rude awakening for some, but as leaders, that’s

what we have to focus on.”

“We also emphasize the importance of

language in what we say and how we say it,” says

Evans. “You can use the power of language to

create a different response in people and to align

them around a possibility bigger than themselves.”

ENLISTING PHYSICIANSIn addition, Cone created a dedicated

physician leadership academy, identifying and

training “rising stars with leadership potential,”

says Amy Martinez, director of organizational

development. “Because of the changes coming

about with population health, physicians have

to be able to collaborate in ways as never before,

which is new for them. In the case of primary

physicians, they are becoming the hub with everyone else being

the spokes turning around them. It’s a big paradigm shift.”

Consisting of a yearlong commitment, the curriculum

includes a personal assessment, measuring everything from

leadership competencies and personality attributes, to an

individual’s appetite for approaching and accepting change.

Executive coaching is also

built in at all stages, including

feedback on action learning

projects, which are designed

to address critical systemic

challenges while serving as

a leadership development

opportunity.

One cohort consisting of 18

physicians has completed the

academy, while another group

of 20 is just beginning. Several

of the physicians who have

completed the program are now

integrally involved in the system’s

strategy effort; another is leading Cone’s ACO; and yet another


“THE TRANSFORMATION STARTS WITH YOU. IT’S A RUDE AWAKENING, BUT AS LEADERS, THAT’S WHAT YOU HAVE TO FOCUS ON.” - JOAN EVANS, VICE PRESIDENT, CONE HEALTH


“For the first time in its history, to get everyone on the same page, Cone elevated its effort to include all employees, staging all-hands meetings at every level. This ‘unleashed a tiger’,” says R. Timothy Rice, CEO, and is paying off in measurable, sustainable results that include:

UNLEASHING A TIGER


Transformational leadership: Leaders must be able to envision and execute on new, unprecedented futures while being highly skilled in the interpersonal skills needed to partner with physicians and care providers and to support and encourage creativity while maintaining discipline.

is immersed in a primary care collaborative effort on

Medical Homes. “This effort was put together to address

the new healthcare era, recognizing that physician

leadership is integral to success,” Martinez says. However,

she notes that juggling meetings while continuing to

see patients “can be very difficult for physicians from

a life balance standpoint.” An underlying goal was to

train more physicians “so the same people aren’t always

carrying all of the load.”

CREATING A COMPETENCY MODELBecause “leadership development is not a one-

time thing,” says Evans, Cone also recently redesigned

its leadership competency model as the basis for its

management development. In 2013, this was integrated

into every manager’s performance assessment, followed

by a development plan and access to tools and resources.

Developed by a group of leaders in a co-creative

process, the model identifies 10 key competencies,

starting with being accountable and including being a

visionary strategic leader, a relationship builder, a leader

of people, having a patient-centered service orientation,

being a talent developer, and a breakthrough thinker. In

addition, exceptional leaders must be effective resource

managers who understand the importance of sound

financial planning, as well as have a keen community

focus and are continuous learners.

GAINING ACCEPTANCEWhile most of the management team at Cone has

enthusiastically accepted the changes the organization

has put in place, the transformation has not come without

some resistance. “By and large,” says Evans, “the people

who can’t make the shift are the exception rather than

the rule. When dealing with resistance, she says there

are two key aspects to consider: 1) Does the employee

have the ability; and 2) Is the employee willing? “No

amount of coaching will help if there is an unwillingness

to change.”

“You may have some people who have been very

successful in the old, command-control model that just

will struggle to make the leap to inspirational.”

For those who do come along for the ride, however,

she says the experience can be nothing short of life-

changing. “Shared commitment and shared vision can

lead to personal transformation,” which brings its own

rewards.

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Are You a Business Statesman?


Accountability is more than just lip service. It’s strategy. BY CHRIS WARREN

FAR TOO MANY ORGANIZATIONS BELIEVE

that creating a corporate culture of responsibility and

accountability simply requires coming up with a statement of

values, putting it on some posters and hanging them around

the office. If only it were that easy. Nathan Rosenberg, a

founding partner at Insigniam, says that culture is much

more powerful and pervasive than a bunch of aspirational

bullet points. “It’s whatever is reinforced and it acts like an

invisible force field,” he says. “Resources and strategy are

important, of course, but a significant part of what people

can and cannot accomplish at an organization is a product

of corporate culture.”

In other words, as much as words matter — and they do

— communication about values only makes an impact when

HOW WELL ARE YOU FULFILLING YOUR PROMISE?

10


it truly reflects how people in an organization act. And that

means that changing culture to become more accountable

and responsible demands a lot of work, especially in healthcare.

Why? Rosenberg believes that the quirky and complicated

business model in which patients don’t pay directly for the

services they receive means providers are often insulated from

the kinds of signals that motivate companies to create cultures

geared around responsibility and accountability to patients.

“It’s not customer satisfaction that drives success. It’s payer

satisfaction,” he says. “No matter how great a job you do, the

federal government or an insurer is only going to pay you X

amount for a particular procedure.”

Accountability has become one of those catchphrases that

is used over and over again without common understanding

of what it means, says Rosenberg. “To give an account is

to give a reckoning — a reckoning of results but more

importantly a reckoning of the actions, and inactions, that

contributed to the result.”

In true accountability, there is a focus on actions. Yes, there

are always circumstances one has to contend with that we

cannot control. Our actions and inactions are how we have

power, the ability to respond. Building cultures in which

NATHAN ROSENBERG


patients, physicians, nurses, and administrators each own the

ultimate outcome, and their actions and inactions to bring

about that outcome, takes a constant

reinforcement of that mindset.

THINK SMALL

For large organizations especially,

the prospect of reorienting a

culture to be more accountable and

responsible can be daunting. Is there

a secret one-size-fits-all approach to

implement systemic cultural change?

No, in fact, there isn’t. At least that

was the experience Richard Buchler

had when he worked with the

Sutter Gould Medical Foundation

(SGMF) in Modesto, California. A part of the Northern

California medical group Sutter Health, SGMF utilized so-

called rapid improvement events aimed at addressing hyper-

specific deficiencies in how the organization functioned to

establish real accountability. With Buchler as a facilitator,

these improvement events brought together a task force of

between nine and 12 people that

always included an administrator,

a physician, frontline workers,

subject-matter expects, and a

patient.

In one instance, Buchler worked

on patient registration, looking for

ways to make it faster, cheaper,

and more satisfying for patients.

Besides coming up with ideas for

improvements, a central task was

instituting accountability. “Each

weeklong event always included a

plan afterward to make sure that any

improvements that were made were tracked and improved

upon long after the event,” he says. “A central part of any

improvement project was setting up accountability. New

processes established were written up as standard work that

UNLESS EVERYONE HAS A ROLE — AND RESPONSIBILITY — TO AFFECT ACCOUNTABILITY,

YOU’RE HEADED FOR A BREAKDOWN.

TAKING THE TIME TO DELINEATE WHO MUST ANSWER FOR SPECIFIC RESULTS BEING ACHIEVED OR NOT IS ABSOLUTELY ESSENTIAL.

all staff were expected to follow at all times.” Managers, too,

were tasked with making sure any new procedures were

followed, and director-level executives were also expected

to do routine “rounding” tours to verify that changes were

being embraced.

DEFINE EVERYONE’S ROLE

Jon Kleinman has a pretty simple way to illustrate the

importance of clearly defined roles when it comes to creating

a culture of accountability. Kleinman, a partner at Insigniam

who specializes in leadership development and innovation,

says it’s best to picture an organization as the pit crew for a

Formula One racer. “That car rolls in for a stop, and you’ve

got just a few seconds to change all four tires, fill the gas,

and do a bunch of other things. You can imagine what

would happen if you had unclear lines of accountability,”

says Kleinman. While often difficult, Kleinman believes that

taking the time to delineate who must answer for specific

results being achieved or not is absolutely essential.

Leaders at Buffalo, New York-based Catholic Medical

Partners have devoted a lot of time and effort to defining

the myriad roles of numerous stakeholders in its network

of 900 independent physicians. “What we have created is a

culture around collaboration,” says Dennis Horrigan, CEO

of Catholic Medical Partners. “They’re a diverse group of

doctors and they’ve told us they want help to deliver better

quality. We helped them by supporting the adoption of

electronic health records so they and their staff could make

better use of technology for care management. We also had

success in advocating with the health plans on their behalf.”

Naturally, this is only part of the equation. Physicians

who are part of the Catholic Medical Partners network

must meet clearly defined standards for delivering

evidence-based medicine, reducing readmission and

infection rates, and other measures. Horrigan says

that Catholic Medical Partners, which has garnered

numerous awards for its use of technology and

quality of care, has also made a significant effort to

encourage patients to play an active role in their

treatment. In part, that involves providing patients

with web-based educational materials so that they

can better understand their illnesses. But it’s also

about ensuring that patients who need it have access

to care coordinators, typically registered nurses, who

can make sure they have the right medications,

arrange follow-up appointments, and visit them in

their homes to see that all their needs are adequately

addressed. Not only does this approach boost patient

involvement and accountability, it also reduces expensive

hospital readmissions.

MEASURE AND RESPOND

An essential step toward creating a culture of accountability

is some sort of objective measure of whether goals are being

met. In the case of Catholic Medical Partners, Horrigan

says that doctors are supplied with a vast array of data

about their performance, along with resources to improve

whenever necessary. “How well do you treat hypertension

and diabetes? They know because we can help measure it,”

he says. “We are identifying areas of improvement and giving

them patient satisfaction data.”

The aim is for doctors to always improve and stay a part

of the healthcare network, says Horrigan. But accountability

also means taking some action when physicians don’t meet

their commitments. “In some cases, we have asked doctors

not to continue in our organization because we don’t think

they are fulfilling their promise,” he says.

LEADERSHIP MATTERS

While it’s true that a few nice words from a CEO are

not enough to establish a culture of accountability and

responsibility, it’s also true that executive team support is

critical. Buchler says little would have been accomplished

during his time at Sutter Health without the backing of key

leaders. “The most important key to setting up accountability

in healthcare is that the effort to do so is led by the CEO,”

he says. “Without his or her buy-in, physicians can easily get

away with doing runarounds of the new processes if they

perceive them as being inconvenient.”



Culture of responsibility and accountability: In order to drive demonstrated value, both patients and providers will need to operate at higher levels of accountability. Organizational and clinical culture, processes, and structures must be organized to institutionalize accountability and responsibility.

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Insigniam Quarterly 2014 Special Edition - Healthcare

Leadership & Management

Transcript of Insigniam Quarterly 2014 Special Edition - Healthcare