The Regional Communities blog is “A weekly compilation of news links about and for regional communities pursuing local and regional development.”

This week our own system is lucky enough to have made the cut for the post Population Shifts, suburban slums, and hospitals.  Have a regional read.

From the Akron Beacon Journal, “Alliance Community Hospital wants to pay you $100 or more to find out how much your health insurer paid for care you received at rival hospitals.”

Hospital’s stated motivation:

Alliance Community Hospital Chief Executive Stan Jonas said the offer is part of the hospital’s attempt to provide consumers with more information about the true cost of medical services.

The hospital plans to share the information eventually on a new Web site.

”We feel that consumers should be able to compare prices before they buy health-care services,” Jonas said. ”We are doing this because we want to prove our value in the marketplace and to provide meaningful comparisons with our own pricing, as well. So in order to help inform consumers, we are seeking information about procedures performed at other hospitals.”

Typical insurer response:

”To the best of my knowledge, this appears to be a new type of initiative,” said Richard Waldron, director of provider networks for Medical Mutual of Ohio. ”While we support the concept of transparency, this initiative seems problematic. Looking through EOBs from unrelated facilities poses issues of data collection, interpretation and validity. Moreover, there may be numerous legal issues inherent in such an effort.”

It would be terrific if transparency is the true motivation. But a hospital isn’t going to shell out that kind of money just so patients can compare prices between hospitals. I have a feeling a competitive market is at least a factor in the decision…

This gem also from the article, “In recent years, ”transparency” has become a buzzword in the medical industry as patients are being forced to foot a higher percentage of the bill.”

Ahh, shouldn’t high quality care be reason number one for transparency?

UPDATE: InsureBlog covers the story and adds a tidbit I was too careless to find: the hospital’s CEO has a blog.

So there are lots of campaigns right now with an aim of calling attention to health care insurance issues. Cutting through the clutter of everyday advertisements/messages/marketing etc. can be a challenge.

Enter the Insur-Animals. “The Worst Animal-Headed Superheroes Ever!” (Their description, not mine.) Self-campaign-deprecation may not be the way to go…

A group in Connecticut offers healthcare4every1 which “is a statewide advocacy campaign committed to organizing an active, vibrant and diverse network of concerned residents to build public and political support for achieving universal health care in Connecticut.” You can read about their campaign here.

That What’s New section hasn’t been updated since August (I’m assuming this is an ominous sign of the campaign’s impact). Regardless, I appreciate the alternative effort. And maybe some chic pop-culture digital artifact to look back upon in 30 years.

As a young, aspiring health care professional, finding a mentor could be a major boon to your career. Not to mention the benefits of being able to discuss health care issues with a real, live health care administrator.

Anyway, once you get that out of the way, Ben Casnocha (a real successful young entrepreneur) offers several tips on proper mentee decorum.

The need for more primary care is quite apparent.  An effort to raise primary care provider reimbursement will be too little, too late.  And for a multitude of reasons—mostly the byproduct of crazy incentives over a number of years—the days of primary care physicians are numbered.

And I’m not so sure it’s a bad thing.

Last week the Wall Street Journal Health Blog asked a simple question, “What will primary care look like in twenty years?”

We know primary care’s messed up. Docs get paid a lot for doing procedures, but not much for sitting with patients, trying to figure out what’s wrong and what to do about it. So where do we go from here?

The post is in regard to a JAMA commentary that lays out several new primary care models that are currently being experimented with including the medical home, see a nurse first, and doctors on retainer.

Primary care’s next model, one that can be well staffed and more consistently reimbursed, will be most like the see a nurse first concept:

A service workers’ union in Las Vegas and Atlantic City is testing a tiered model where patients see more of “nonphysician clinicians and staff” (sounds to us like advanced practice nurses, physicians assistants and the like). The physicians manage the team and provide direct care for patients who have more complex medical problems, and oversee the nurses who treat the healthier patients. The authors note that basic prevention and screening visits may not be a cost-effective use of a physician’s time in many cases.

The shortage of primary care physicians has been well documented.  Another reference.  And for good measure.

Merrill Goozner of GoozNews writes about “Reform Woes,” and describes our problem of so few primary care physicians, “The U.S. doesn’t have too many doctors, it has too many specialists — about 70 percent of the total. In Europe, the ratio is almost exactly reversed — 70 percent primary care and 30 percent specialists.”

Jeff Goldsmith has a post at The Health Care Blog outlining the ramifications of an aging physician population (read: retirement) and a new breed of physician whose values are very different from the group proceeding them.

We know there is a problem.  The question, then, is what are we doing to do about it?  We should not pin our hopes on law makers realigning incentives to encourage more medical students to enter primary care practice.  So let’s work with what we’ve got, and maybe a few innovations that are in the currently in the pipeline, to solve our issues.

What do we need from primary care?

My simplistic answer is this: our primary care model should be one that treats the most common diagnoses, provides disease management services, and refers more difficult issues to specialists.  And we don’t necessarily need a doctor to perform these services.  Advanced practice nurses, physician assistants, and pharmacists are three groups of providers who can all perform these functions.

The Wall Street Journal recently had an article about nurses attaining their doctoral degrees.  These “Dr. Nurses” will be able to provide primary care:

More than 200 nursing schools have established or plan to launch doctorate of nursing practice programs to equip graduates with skills the schools say are equivalent to primary-care physicians. The two-year programs, including a one-year residency, create a “hybrid practitioner” with more skills, knowledge and training than a nurse practitioner with a master’s degree, says Mary Mundinger, dean of New York’s Columbia University School of Nursing. She says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings.

Yesterday, the WSJ Health Blog posted about pharmacists and primary care roles:

People have been toying with this model for years, and a new paper in the Archives of Internal Medicine is further evidence that the concept has legs. Regular consults with pharmacists significantly reduces hospitalization rates for people with heart failure, according to an analysis of 12 randomized trials.

Not to mention physician assistants who have been performing the primary care role for years.

Adding a number of primary care providers to the system should be sincerely welcomed.  It will allow and encourage providers to spend the appropriate amount of time with patients.  More providers will encourage innovation and experimentation with new delivery models, like this one: the reemergence of the house call will allow patients better access, as this Boston Globe op-ed describes:

Close your eyes and envision a physician carrying his or her black bag to make a house call on a frail elderly person, someone with a disability, or even an aging baby boomer. Does this image seem as outdated as multi-week hospital stays? Actually, house calls, with their potential to lower costs while improving healthcare quality, are more relevant than ever.

Today, a disproportionate percentage of rising healthcare costs are tied to the expense of caring for those with complex chronic illnesses and serious disabilities. This population cannot easily get to the doctor’s office or have their needs met in a 20-minute visit. In our approach to caring for these patients, there are many missed opportunities to prevent complications requiring costly hospitalizations and nursing home placements.

One of the interesting aspects of a redefined primary care model is the change in employment structure of the primary care provider: moving from the doctor who is self-employed to the providers (nurses, pharmacists, PAs) who will be employed by hospitals and clinics.  While organizations will take on more risk associated with malpractice, the benefits could help reform our delivery of care.

The World Health Care Blog has a related post.  This excerpt highlights the challenge of moving away from the primary care physician to the more broadly defined primary care provider:

More recently, the medical profession has taken on developments such as retail clinics which use nurses or physicians’ assistants, rather than physicians, on grounds of quality concerns.  The fact that these clinic offer more convenient care at lower prices, hence take away lucrative patients and visits from physicians is by no means ignored, though never mentioned by physicians, themselves, as a reason for their objections.

If physicians don’t want (or are unable) to practice primary care, why fight it?  We have very capable individuals who could step into the roles of primary care that are most needed and do a wonderful job.  Redefining primary care functions, and those who serve in the roles, is a needed change in our system.

Coincidentally, a couple of relevant mafia stories…

If we’re in need of a scapegoat for any health care insurance reform, Dr. Jonathan Kellerman has found the party in a biting Wall Street Journal opinion piece:

The health insurance model is closest to the parasitic relationship imposed by the Mafia and the like. Insurance companies provide nothing other than an ambiguous, shifty notion of “protection.” But even the Mafia doesn’t stick its nose into the process; once the monthly skim is set, Don Whoever stays out of the picture, but for occasional “cost of doing business” increases. When insurance companies insinuate themselves into the system, their first step is figuring out how to increase the skim by harming the people they are allegedly protecting through reduced service.

Once they affix themselves to the host – in this case dual hosts, both doctor and patient – they systematically suck the lifeblood out of the supply chain with obstructive strategies. For that reason, the consequences of any insurance-based health-care model, be it privately run, or a government entitlement, are painfully easy to predict. There will be progressively draconian rationing using denial of authorization and steadily rising co-payments on the patient end; massive paperwork and other bureaucratic hurdles, and steadily diminishing fee-recovery on the doctor end.

He actually suggests ridding ourselves completely of insurance, it’s worth a read.

The Guardian, last week, had an intriguing story on how to do (good) business like the mafia.  Despite some of the questionable tactics employed by the mafia over the years, Clare Longrigg writes there are lessons to be learned from organized crime.  My favorite (of the seven):

Rule 6: Reinvention

In case of a political scandal, or a business failure, it is vital for the new boss to be able to distance himself from the whole affair. Indeed, he may find it useful to take on a new persona altogether. When Stuart Rose returned to Arcadia after three years to rescue it, he said: “What is interesting is that people here think I haven’t changed, but I have been gone three years. I am not the same Stuart Rose, I have changed a lot.”

With Provenzano’s new directives, not only did the negative headlines cease, but he managed to dissociate himself from the scandals that had gone before. Like everyone else, he had emerged from Cosa Nostra’s most violent decade with his reputation in tatters; his advisers helped him to “get his virginity back”, in Giuffrè’s interesting phrase. With the help of his PR-savvy advisers, he made sure no one associated him with the violent years, and created his image as the peacemaker.

“When I got out of prison,” Giuffrè recalled, “I found Provenzano a changed man; from the hitman he once was, now he showed signs of saintliness.”

Last week, Marketplace had a story about a medical-legal partnership that is helping to reduce the cost of health care in the U.S.

The innovative partnerships—which are popping up around the country—are hiring “attorneys to help fight illness and disease among the poor.”

Poor families, with no alternative, bring their sick children to the emergency room. Not only is this about the most expensive way to get healthcare, the conditions that bring impoverished kids back to the ER again and again are often preventable. Ellen Lawton is executive director of the Medical-Legal Partnership for Children at Boston Medical Center.

Marketplace describes how the partnership can help, “Say a disadvantaged child lives in an apartment with a leaky pipe. The landlord refuses to fix it, even though the leak is causing mold, and mold can trigger respiratory problems.”  The partnership then makes the situation officially legal and forces the landlord to act.

Dr. Barry Zuckerman of the Boston Medical Center explains the value of the partnership to the hospital:

So our lawyers, by helping out the patients, actually also accrues value in dollars to the hospital, because in many cases they can find that such-and-such a condition was covered, and the hospital should be paid for the services that was provided to the patient.

The partnerships are quickly expanding (now number over 80) and are targeting the problems of patients at a variety of ages with a variety of conditions.  The medical-legal partnership may have created strange bedfellows but it’s proving positive outcomes.  Are there other partnerships that could help us attack health care’s issues?  Local government?  Other non-profit agencies?  Business?  We can, and should, all work together to solve our many issues.

Have you heard of the Geek Squad? From their website: “Geek Squad Agents, Advisors and Installers teach people to embrace technology fearlessly and practice the art of human interaction.”

In order to offer patients more care options (and a throwback to the days of old), our own system will deploy the Doc Squad (still deciding whether to outfit them with Beetles or not) to respond to individuals who need attention at home. These providers will be able to provide basic general practitioner duties in the patient’s home.

Jay Parkinson and a few others are practicing virtual medicine…but why couldn’t this innovative solution be employed in the hospital? Well it can. And we will.

The Health Care Blog has a good piece on Dr. Parkinson. The best quote:

“The healthcare industry is so stuck in 1994,” he says, “The only way they’ve used the Internet is to provide information. I look at the Internet as something that provides communication.”

Principle #14: 1994 or not, it’s time that we (hospitals) start deploying new business models. The Doc Squad is our own system’s version of a previous era doctor’s house call. Every decision we make should make the process easier for the patient. Period. And if you’re not innovating for the patient (or the patient’s well being) you shouldn’t be innovating. Period.

From the WSJ Health Blog:

“Medicare should pay more for primary care and less for procedures and specialty care, a Medicare advisory board said at a meeting this week.”

Maggie Mahar at Health Beat is doing a series on health care spending related to hospitals; Part I and Part II. Here is a snippet from Part II (go read the rest, it is quite informative):

In recent years, much new construction has been designed to house new technology or upgrade amenities rather than add to the number of hospital beds. There is just one exception to that rule: the suburbs.

“When hospitals do increase inpatient beds,” Paul Ginsburg, the president of the Center for Health System Change notes, “the new construction typically occurs in rapidly growing suburbs, where well-insured patients live.”

In its March 2008 report, the Medicare Payment Advisory Commission supports Ginsburg’s observation: “much of the added capacity is located in suburban areas and in particular specialties, raising the possibility that health care costs will increase without significantly improving access to services in lower income areas.”

While having a hospital in every suburb might seem like a convenient idea, the fact is that we cannot afford to duplicate multi-million dollar equipment that is available in a large city 45 minutes away. Here, I am not talking about emergency equipment or trauma centers; I’m talking about positron emission tomography (PET) machines and neo-natal intensive care units.

In order to offset notorious money-losing locations (read: depressed areas) health systems have built hospitals in suburban areas where the payer mix is much more likely to be profitable. It’s really a smart business decision, but as Ms. Mahar notes, the redundant and expensive technology is sending health care costs up. That’s a problem, but here is something else to consider: what happens when Americans stop moving to the suburbs?

Would people really do that?

They are. The Atlantic had an article in March that noted the emergence of suburban slums:

The decline of places like Windy Ridge and Franklin Reserve is usually attributed to the subprime-mortgage crisis, with its wave of foreclosures. And the crisis has indeed catalyzed or intensified social problems in many communities. But the story of vacant suburban homes and declining suburban neighborhoods did not begin with the crisis, and will not end with it. A structural change is under way in the housing market—a major shift in the way many Americans want to live and work. It has shaped the current downturn, steering some of the worst problems away from the cities and toward the suburban fringes. And its effects will be felt more strongly, and more broadly, as the years pass. Its ultimate impact on the suburbs, and the cities, will be profound.

Arthur C. Nelson, director of the Metropolitan Institute at Virginia Tech, has looked carefully at trends in American demographics, construction, house prices, and consumer preferences. In 2006, using recent consumer research, housing supply data, and population growth rates, he modeled future demand for various types of housing. The results were bracing: Nelson forecasts a likely surplus of 22 million large-lot homes (houses built on a sixth of an acre or more) by 2025—that’s roughly 40 percent of the large-lot homes in existence today.

For 60 years, Americans have pushed steadily into the suburbs, transforming the landscape and (until recently) leaving cities behind. But today the pendulum is swinging back toward urban living, and there are many reasons to believe this swing will continue. As it does, many low-density suburbs and McMansion subdivisions, including some that are lovely and affluent today, may become what inner cities became in the 1960s and ’70s—slums characterized by poverty, crime, and decay.

Richard Florida writes on a host of issues including regional development, quotes a San Francisco Chronicle article on his blog:

When asked if the edge suburbs are turning into slums, Florida concurs with Leinberger’s ominous vision. “Yes, they are already well on their way,” he says. “The knowledge workers can’t afford the time cost, they can’t afford the commuting time.” …Florida and Leinberger say that retooling the suburbs is going to make urban renewal look like a walk in the park. “Suburb development is really fragile,” Leinberger explains. “It’s going to be very complex to rebuild.”

A CNNMoney.com article from 2006 notes that it is not just young urban professionals who no longer want to live in suburbia:

Retirees, empty nesters and young professionals usually have little in common, but they’re all in the vanguard of a recent trend - they’re repatriating center cities.

The trend, which began in the late 1990s, marks a reversal of the post-war urban flight to the suburbs. Now, it’s strengthening.

Young professionals make up a big part of the trend. “It’s carefree living,” says Caparo. “Young professionals just want to put the key in the door and go to bed at night and lock it up again in the morning.” It’s also where the action is, professionally and socially. “For them, there’s lots of DNA to hook up with,” says McIlwain.

Retirees love the museums, restaurants and, most important, access to the best health care. Empty nesters get to live near work.

“For years people traded a commute for affordable housing,” says Jim Gillespie, CEO of Coldwell Banker. The further out in the suburbs, the more affordable the homes. But as suburbs expanded and got more crowded, road construction did not, could not, keep up. Congestion grew worse.

So what is the problem? The closing of SSM St. Francis Hospital and Health Center is a start. Hospital closings are rare, their economic impacts are very important to the communities they serve. Jane Sarasohn-Kahn at Health Populi writes about those difficulties:

Always remember that one worker’s income is another one’s cost. For some communities, the hospital is the local monopsony providing the lion’s share of meaningful employment.

The chart on the right from the AHA study illustrates that in many states, hospitals provide at least 1 in 10 jobs: this is true for Maine, North Dakota, Pennsylvania, and nearly 1 in 10 for Massachusetts, Michigan, Missouri, Ohio and West Virginia, among others.

The microeconomy of the hospital is thus a major contributor to the States’ and nation’s macroeconomy.
When there’s talking of closing hospitals, there’s no doubt why it’s so tough to do so. Financing hospitals, appropriately, has implications well beyond “the bed” and the individual patient.

So localities will fight to keep their hospitals open even as population shifts render their locations irrelevant and unnecessary.  Not necessarily a good thing.  The more unnecessary hospitals we have, likely the more unnecessary hospital spending that will occur.

Ms. Mahar sums it up best:

Granted, out West, there are states where hospitals are too far apart. But in the Northeast, on the West Coast, and in many areas in the South, research shows that we already have too many hospitals—leading to supply-driven over-spending and over-treatment. (“Build the beds and they will come.”)

Here is what we need ask ourselves: are we building responsibly?  What happens when (we’re approaching unsustainable spending levels) government decides to say to hospitals “you made your bed, now sleep in it?”