Caught in "too big to care"?

 There have been two compelling articles in the “New York Times” over the past few weeks focused on healthcare. The first article dated Tuesday, October 30, 2018, is entitled “A Sense of Alarm as Rural Hospitals Keep Closing1 and the second article dated November 14, 2018, entitled “When Hospitals Merge to Save Money, Patients Often Pay More2. These two articles are really bookends of the same set of issues emerging in our healthcare delivery system.


"Since 2010, nearly 90 rural hospitals have shut their doors. By one estimate, hundreds of other rural hospitals are at risk of doing so." 1 In many communities these hospitals are amongst the largest employers in the area. Because of the availability of medical care, communities establish a sense of stability that sustains existing businesses and presents opportunities for new commercial enterprises. The reality is that the cost of delivery of healthcare, which continues to accelerate, makes these rural institutions less capable of sustaining the level of quality of care emerging in this era of rapidly expanding technologies.


Do you stay or go?


These rural community hospitals are relegated to providing primary care services and very few of the specialty services that are available in centers of medical excellence in metropolitan cities. This situation continues to increase the need for patients to migrate to larger communities in order to obtain the specialized services their healthcare will require. This raises an interesting paradox addressed in the second article focuses on increased consolidation of healthcare services in huge healthcare systems with almost monopolistic power in key healthcare markets. "The latest giant hospital consolidations continue to stir concerns. Dignity Health and Catholic Health Initiatives, two large chains are expected to become one of the nation’s largest groups ---- with 139 hospitals in 28 states--- by the end of the year. And two of Texas’ biggest systems, Baylor Scott & White Health and Memorial Herman Health System, recently announced plans to combine.” 2

Piggy bank and stethoscope resting on pile of dollars on white background


"In the national analysis, a third of the metropolitan areas experienced increases in the cost of hospital stays of at least 25% from 2012 to 2014, from roughly $12,000 to at least $15,000.”2 Thus, these hospital system consolidations are doing exactly the reverse of what was anticipated as they are continuing to accelerate the cost curve rather than bend the curve with additional savings.



When you look at this emerging picture of healthcare from the perspective of the individual from a rural community who needs specialized care, the system is fraught with confusion, anonymity and increasing costs. We at Curus referred to this as the "What do I do now? syndrome". In order to seek out the highest quality of care, patients are left to their own ingenuity to figure out what are the best options that are most cost-effective and are in network? This is where the doctor-patient relationship is devolving into an impersonal process where the patient is on the conveyor belt of healthcare delivery. Further complicating the decision-making in this scenario is the fact that physicians are becoming part of the "corporate practice of medicine". While legally that phrase has certain implications in the real world, it represents the fact that physician affiliations to these monolith healthcare systems or to huge practice groups dictate much of the decision-making with regard to the referral patterns to specialists. 

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A patient coming from a rural hospital is at the mercy of the system in which he/she seeks specialty care. They no longer have the familial relationship with the provider that is the historic bedrock of care in rural communities. When we started Curus, we were often confronted with the question of, “What do I need a healthcare manager for?” As we see the continuing consolidation of the healthcare delivery system where the patient has ceased to be the focal point of the care delivery process, the question has begun to answer itself. Without a dedicated team of skilled healthcare professionals who understand the nuances of the healthcare process, patients are directed rather than engaged by the healthcare professionals. They are part of the system, a process.  As one physician told me recently - when the healthcare systems are run by “bean counters”; the role of both the patient and the doctor suffer.    


In 2007 and 2008, the nation talked a great deal concerning the financial industry about the problem of "Too Big to Fail". Well, surprise! That is exactly what's happening in healthcare today. Systems of tremendous power are centralizing the delivery process and the patient has become a commodity in the system. In our Curus model the patient is the center of the universe. That's what being patient-centric means. Our role is to ensure the best possible choices so that our members can make value judgments that we can assist them in implementing. Our fundamental goal is to return control of the health care process to the recipient of that care. The reason one needs Curus to coordinate, navigate and evaluate all aspects of the continuum of care is to ensure that the human side of the healthcare experience is one of top quality care, compassion and concern.  


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Filed Under: Insider, Traveling, Health Management, doctor shortages, healthcare quality, changes in healthcare, pros and cons of concierge medicine, medical access

Healthpoints: Filling the Provider Void

In the recent past, the government was evaluating the concept of Medical Homes with Primary Care Physicians (PCPs) serving as the active navigator of their patient’s health care. This was an innovative theory; but in practice, it was highly unlikely to have a substantial impact on the delivery of care. At the same time as the government was proposing this solution to the conundrum of care availability, the reimbursements doctors were receiving for various services, procedures and tests were reduced. This reduction meant PCPs would have to see more patients to maintain a level of income commensurate with the sacrifices they have made in their lengthy education.


There was an interesting article on this week “NPs and PAs: Growing by Leaps and Bounds.”  The article indicated that while the number of physicians is increasing by over 1%, the numbers of Nurse Practitioners (NPs) and Physician Assistants (PAs) are growing even faster at a projected rate of 6.8% for NPs and 4.3% for PAs.  This influx of non-physician providers is another indication of the rapidly changing landscape within the American health system. This as another example of American ingenuity - to find solutions to complex problems while allowing an evolutionary process to occur.


NPs and PAs can spend more time with the patient. Their caseloads are designed for them to allow almost twice as much time with each patient as a physician would have. This leads to the patient having the ability to express their concerns more effectively as they feel less pressured during the visit. A recent study showed physicians tend to interrupt their patient every 3 seconds, while an NP would make a comment every 12 seconds. In the environment of an exam room, this level of attention is very helpful to creating a patient friendly atmosphere. In patient satisfaction studies, making the initial point of contact with an NP or PA is increasing patient satisfaction.


The increasing use of artificial intelligence as a diagnostic tool is also changing the way healthcare is delivered. Much like the automobile industry has changed. When you take your car in for service, it is astonishing how they plug-in a set of diagnostic tools and, with pinpoint accuracy, diagnose the problem. We are certainly headed the same direction in healthcare. With increasing miniaturization of technologies, phone applications are now possible. You can now take a two lead EKG with your phone and forward it instantly to a doctor.


Advances in diagnostic tools, combined with the increasing sophistication of NPs and Pas, are disrupting the old care delivery process in a positive way.


Good listening has always been the best diagnostic tool. Now patients will have more time to communicate their concerns. When you combine the time available to listen of the NPs and PAs with the technology breakthroughs that are continuing to emerge, patient satisfaction should continue to increase.


In no way does this change delivery or denigrate the fundamental role that physicians play in assuring that we are receiving the best healthcare possible. They remain the center of the delivery system around which all of these providers and new technologies revolve. This just allows more patients to be seen, and PCPs to be able to devote their time more effectively.


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Filed Under: doctor shortages, healthcare quality, patient satisfaction