Hospitals continue to cope despite arguments of severe nursing shortages. Take the state of Iowa for example, where officials say that current nurse staffing runs 8% below the desired level and could reach 27% within ten years. Nationwide, the country could run a deficit of 340,000 nurses by 2020.

Although slowing, United States population growth should reach nearly 400 million by 2050. All the baby boomers should be retired by then, too. We see the need for nurses.

FastCompany has a blog called The Big Idea (which more or less is a thought of the day) and one day last week it was this, inspired by the California Department of Finance: “You can build all the walls you want, but this country is going to have a Hispanic majority by 2050. ”

I haven’t seen nurse shortage predictions that extend to 2050, hopefully we have some game-changing innovations in nursing care by that time to quell the need. But, right now, the responsibility falls to hospitals to reach out to these new Americans and encourage them to pursue a career in health care, especially nursing.

We are going to need the help. Here’s a story of something like this already happening. But the idea needs to spread beyond traditionally Hispanic (Texas, California, etc.) states.  We’re going to experience the shortage everywhere and this new population can provide the help in every corner of the country.

Who is opening for you?

Late night talk shows have a person dedicated to warming-up the crowd before Conan, Dave, Jay, or Jimmy start the monologue.  Headlining bands around the world do the same thing when they utilize opening bands during live concerts.

First impressions matter, a lot.  First impressions matter in a job interview.  First impressions matter on a first date.  Even magazines pay attention to first impressions.

This is important in our hospitals, too.  The unhappy (or even just blah!) person at the registration desk sets the tone for the rest of my visit.  Driving around a complex medical campus, frustrated, just trying to find where I am supposed to go starts my visit down the wrong path.  The volunteer that greets me with a smile as I walk in the door could make all of the difference.  The cleanliness of the hospital’s grounds and facilities, the serene water piece near the entrance, the amount of paperwork I have to fill out before my visit, the amount of time I wait before seeing a provider, all matter.  The list could go on.

First impressions are so fragile–it truly takes so little to make a good one (or to go horrendously awry).  A hospital can manage a patient’s experience.  Setting the tone that this hospital is different, that this hospital truly cares about about the patient, can make all the difference.

Who is opening for you, more importantly what’s your opening act?

Search any hospital/health system/practice group human resources job listings and you may realize the challenges in keeping a health care organization fully staffed. If not, search Google for nurse shortage, physician shortage, or read stories like this and this.

Trend: difficult human resources issues.

Some organizations are trying different kinds of benefits, others are trying referral programs, others are trying…

Those types of solutions may be important, but, turbulent times call for new solutions. Well, maybe it starts with Seth’s suggestion of renaming the department to Talent. It could be a difficult maneuver in the traditionally stodgy health care environment, but that’s the point here: this kind of disruption, this fundamental change in how we do business, how we approach opportunities and solutions, how we treat employees, has the potential to excite (it does for me!) people. Talk to someone who works at a new Pebble Project hospital and find out many people applied for the limited number of jobs: the facilities, ideas, and approach to care are different and that brings droves of applicants onto the scene.

But we don’t have to build a new hospital to approach health care in a different way.  Seth (as always thoughtful and completely insightful, and if you haven’t started reading his blog, you need to start, today) says:

Like it or not, in most organizations HR has grown up with a forms/clerical/factory focus. Which was fine, I guess, unless your goal was to do something amazing, something that had nothing to do with a factory, something that required amazing programmers, remarkable marketers or insanely talented strategy people.

Hmm, health care is an industry in deep trouble.  Thinking differently is going to help us get out of the mess: doing something(s!) amazing is the strategy.

It’s not a new concept. In fact, I would be willing to bet that if you ask older individuals and those living in rural areas most of them would tell you they have a family physician or primary care physician. Believe it or not, patients actually call and make appointments with one physician for every medical problem they encounter. That physician then treats or refers. Easy concept. The family physician or primary care provider serves as a gatekeeper to the rest of the system. Difficult today for a variety of reasons.

This article on the American Academy of Family Physicians website says the medical home “is both old-fashioned and thoroughly modern - a blend of the personalized, comprehensive care that family physicians have been offering for decades and coordinated care that capitalizes on new technology and helps patients make sense of the increasingly complex health care system.”

Medical homes are gaining traction in the here-and-now. And for very good reason. When you read this editorial by Dr. Benjamin Brewer at the Wall Street Journal I think you will see why.

Recently, the Illinois Medicaid program decided that nearly every recipient of public aid needed something called a “medical home.” The idea is to provide an accessible, lower-cost point of entry into the health-care system than a hospital emergency room. A practice that agrees to provide the home makes a commitment to take an active, integrated approach to coordinating a patient’s medical care.

The American Academy of Pediatrics “describes the medical home as a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care.” Their website can give you a comprehensive rundown of medical homes.

Dr. Brewer goes on:

Patients and their doctors have 24-hour access to the information or advice from us by phone or email. We provide prenatal care, delivery services, child and adult care in the office and the hospital. We measure our quality quarterly by looking at some key indicators. We don’t avoid patients of any age or gender or those with chronic, pre-existing conditions. We maintain a list of available specialists and coordinate referrals and follow-up.

All for around $2 per patient per month in addition to office visit fees for services. It seems impossible in our $2 trillion health system. But Dr. Brewer says he is doing it. The care that was once provided free is now being reimbursed.

What’s missing in the debate over our nation’s health-care crisis is that primary care is cheap. Cheaper than your cellphone bill. Cheaper than a tank of gas. Cheaper than dinner and a movie. It’s so cheap the average person doesn’t value it properly. I could have covered my salary for 2007 and the costs of all my staff and overhead for less than $20 per patient per month, including maternity and hospital care.

I’ve blogged about private industry making change in health care on this blog before and have referred to this article as well, but it is worth noting again–a group of employers is partnering with Bridges to Excellence to pay doctors for creating medical homes for patients. “The initiative is the latest and perhaps most far-reaching effort by Bridges to Excellence, a program backed by big employers and health plans and a big player in the movement to provide physicians with financial incentives for taking better care of patients.”

But considering how often we introduce new ways to deliver care and then how quickly those innovations disappear the implementation and effectiveness of the medical home is dependent upon a variety of factors.  According to the AAFP article, “Whether the concept takes root may depend on two key issues: whether payers can be convinced of the value of medical homes (and the need to pay more for them) and whether physicians can deliver what the medical home promises.”

The concept is not new. But it seems to have been forgotten. If it can help the uninsured, stymie health care costs, and make us healthier, it should be obvious that we need to explore this option further. Any thoughts?

Some more reading here that debates some pros and cons.

TransforMED is working to implement the medical home concept through its mission “The mission of TransforMED is to lead and empower medical practices in implementing the new model of patient-centered care — thereby improving health care for their patients, as well as the success of their practices.”

Ideas, ten of them.  Worth exploring.

An addition to a previous post.

The Wall Street Journal gives us another example of private industry backing an organization dedicated to reducing health care costs and improving quality.

Bridges to Excellence pays doctors bonuses for higher quality care. According to the article, “Last year, the program paid out roughly $10 million in bonuses to doctors in the 18 states where it is active.”

The Hartford Courant brings us a story of play in the ER…to learn of course.

Basically a group of employees play a board game that simulates a very stressful 24 hours in the ER. The employees work together in order to navigate a host of issues. The purpose is to promote efficient decision making, collaboration, and learning.

I think it’s a great idea. And I think we’ll see more of it. However, can’t someone come up with a role playing game on the Wii (at the least on the computer)? Board games are so passé (except for Candy Land).

Thoughts?

Came across a couple of innovative health care websites (read Health 2.0) in the last couple of days.

The first is SharedFunding, an employer focused company that manages high deductible health plans for companies. The website says:

Through our research we determined that when an employer purchases a high deductible health plan, and provides a benefit for the employee “below” that deductible, the employer appreciates significant savings.

SharedFunding has already saved employers a phenomenal amount of money by allowing them to appreciate strong benefits at lower costs. And, our technology and service liberates you and your employees from the complex web of healthcare claims processing.

The second is a startup from Minnesota called Carol. The Star Tribune has an article about the new company. The Health Care Blog has an interview with CEO. The company provides a marketplace where consumers can quickly self-diagnose and then select a provider that will provide treatment. From the Star Tribune:

Ankle pain? Click on the matching body part and two options pop up. For $199, doctors at Sports and Orthopaedic Specialists will check out your ankle, review your medical history and recommend treatment. TRIA Orthopaedic Center lists a similar package for $213 — and a reminder that they are the team doctors for the Vikings and Timberwolves. What did patients think? Read user reviews. Will your health plan pay? Tap in your details and find out.

The website is easy to navigate. It’s a great idea. I think the best part is that it allows consumers to make a health care choice based upon price.  OK, something I like even better is this notion of bundled services.  Providers who use Carol list their services in one nicely-priced package.

The website allows consumers to compare services by different providers and lists exactly what the price covers. They do have a section that contains a quality statement by each provider–this could be improved. So far, not too many providers have signed up, but I think it is only a matter of time for providers to take action as more consumers start using the service.

Found this at Fast Company:

Colin Evans, 55, is a 27-year Intel veteran who’s on loan to Dossia, a nonprofit consortium founded by several major companies, including AT&T, BP, Intel, and Wal-Mart, to create a portable electronic medical record.

To go along with The Leapfrog Group; which was created:

In 1998 a group of large employers came together to discuss how they could work together to use the way they purchased health care to have an influence on its quality and affordability. They recognized that there was a dysfunction in the health care market place. Employers were spending billions of dollars on health care for their employees with no way of assessing its quality or comparing health care providers.

Private industry has felt enough pain with health care in the United States to develop these skunk works-like groups to find solutions.  We need to find sustainability.  If we don’t start the change from within, it is obvious that outside forces will.  Being forced to change is never easy.  Embracing change is the answer.  Private industry has sent the message: if we don’t, they will.

As you all know the United States spent $2 trillion+ on health care in 2006. Not that we needed to surpass such a milestone to toke the flames of the how-to-cut-costs debate, but it seems like a good reason to start that conversation here. We’ve been talking about preventive care for a while now and as far as I can tell there hasn’t been much action.   Plus, most of the presidential candidates (save for a couple of republicans) claim (on their websites) cost savings would be generated if we only utilized preventive care.

A quick Google search didn’t turn up any specific citations of how much preventive medicine could save. In fact, the National Center for Policy Analysis (they tout themselves as a “nonprofit, nonpartisan public policy research organization” cites several studies that show no improvement in health and claims:

But study after study has shown that preventive medicine adds to overall health care costs. The reason is fairly straightforward: Testing everyone costs a great deal of money, and the diseases being screened for are fairly rare. At best, the tests benefit only a few. And the savings generated by early detection of these few instances of disease are far outweighed by the costs of testing large numbers of people.

But Health Beat (I’ve been citing them a lot lately–there is just so much good stuff there) gives this anecdote from my home state of Minnesota:

This is also true (of preventive care benefits) in the U.S., in states like Minnesota, where there are many more primary care docs and many fewer specialists than in Southern California. After adjusting for differences in race, sex, age and overall health of the population, it turns out that care in Minnesota costs half as much–and outcomes, patient satisfaction and health are better. So it could happen here, without single-payer. We just need to limit the supply of specialists and make more primary care available and affordable.

So there is some decent debate to be had here.

But to my question: why hasn’t anyone seriously tried a preventive care model? This would be a lot of work (but a great experiment): a small to medium sized health care system (that utilizes a physician-as-employee model) would negotiate contracts with insurance companies to insure reimbursements do not dip below a pre-specified level during the duration of the experiment. But over (say) a two-year period the physicians and the hospital system would implement a preventive care strategy for all patients (while still providing traditional medical care). Obviously a great deal of planning and pre-implementation strategy making would have to occur.

My explanation is simple, but that’s the basic idea. Who would lose here? Insurance companies potentially (if preventive care adds a great deal of costs) but I would still argue it would be a very worth while experiment for them. The other problem I foresee is the fact that much preventive medicine doesn’t show its benefits immediately, it’s a long-run investment (which I am assuming is a large part of why there has been so little investment, businesses don’t see the payoff if an employee would only stay for five years).

There is some pretty important conversation to be had in regard to preventive care. I think we need to start thinking long-term, short-term fixes are exactly that. Could this experiment potentially work?

PS: This looks like an interesting for-profit foray into preventive medicine.