It is clear to all associated with healthcare that the redesign of the
industry is high on the national strategic agenda. We all know that many
parts of the health delivery system in the US are broken: overall consistent
quality is mediocre; service metrics reported through HCAHPS are poor;
business literacy is in jeopardy as evidenced by predictions that over
1000 hospitals will be bankrupt by the end of 2013, and community value
as represented by the amount of charity care provided by non-profit hospitals
and health systems is under scrutiny by the Federal Government.
Redesign of American health care will most likely be evolutionary rather
than revolutionary. In this case, it is imperative that all of us who
are privileged to work in this industry spend significant time looking
at the pieces of the puzzle that could be put together to create a new
delivery process which would significantly improve the performance areas
outlined above.
Based on some clinical experiences, both past and present, I am proposing
that one piece of the puzzle may be for providers to get increasingly
comfortable with segmented healthcare as part of the solution. What specifically
am I suggesting?
I define segmented health care, which I experienced many years ago in my
internship and residency, and more recently in Mexico, as the provision
of healthcare in different settings with different amenities according
to the patient’s ability to pay for such amenities. I know that
many people initially will react to this idea by asking, “Are you
proposing different levels of healthcare for the poor and the rich?”
Absolutely not! Rather my proposal is to provide equitable health care
for all from the clinical, safety, and service perspectives, but not providing
equal amenities to all.
I am convinced that some of our struggle to control our healthcare costs
in the US is due to the fact that we are providing private rooms with
flat screen TVs, free telephone access, free internet connections, and
menu selections to many who cannot afford them. If patients wanted such
while hospitalized 25 years ago, charges for these additional, non-crtitical
items would be added to the bill. In addition, today we allocate large
spaces in our lobbies, waiting areas, and other non clinical locations
to environmental pleasantries such as fountains, trees, artwork and even,
chandeliers. Yes, it all creates a great impression but, in the long term,
these amenities add to overall costs, none of which is off-set by revenue.
In order to consider this transformational strategy we will need to undertake
a re-educational process with our patients and their families, informing
them that we are committed to equal quality and service for all, regardless
of their ability to pay, and that we can provide certain, non-critical
amenities only if they wish to pay extra for them. We need to remind those
who enter our doors, often for only a short time in our hospitals, clinics
or other outpatients programs, that many amenities add no value to their
care, and in fact, will probably not be missed.
An example of this concept in another industry is demonstrated when we
go to buy a car. Adequate transportation is the expected outcome, but,
some of us can only afford a used car, while others can buy a luxury model.
Yet we all reach our goal! If you transfer this analogy to healthcare,
I think you might agree we are giving sunroofs and high-class stereo systems
to everyone, even those who can only afford the cheaper models. This practice
is adding to a cost structure that is not sustainable. Again, we must
remind people over and over again that we are not sacrificing quality
or service, but in fact only wrapping the package differently based on
the patient’s desire and ability to pay.
I know there are many reading this blog asking, “Can we safely go
back to wards with two and four bed rooms with the infectious disease
issues facing us today and the critical illnesses we are seeing in our
hospitals? The answer is clear. If a patient’s severity of illness
is significant, they are moved to special care units whose physical layouts
need not be changed. In ICUs, CCUs, Isolation Rooms, and the like, the
“amenities” are mainly focused on the high technology required
by their providers.
I readily admit that this proposal, as one piece of the puzzle for the
redesign of healthcare, may seem radical and interpreted by many as a
step backward rather than forward. Yet based on our experience, the Partners
at Royer-Maddox-Herron Advisors are convinced that a segmented health
care system is at least worth putting on the table when discussing transformational
strategies.