Top Trends for 2009

Webinar: December 9 and 18, 2008

                                                                Pre...
Noblis Center for Health Innovation – Top Trends for 2009

             Changing Consumer Demands


  Budgets Trimmed - In...
Top Trend #1: Consumer Demands will Continue to Change

 Utilization Trends will be stable or even decline in all but stro...
Despite Historical Trends – Utilization will Be Stable or Decline
in All But Strongly Growing Markets

               US P...
Once Thought to Be Recession Proof – Health Care is
 Feeling the Effect of the Downturn
 HCA with 160 hospitals reported f...
Consumers Will Continue to Redefine Value to Include
Communication, Information, Access, and Outstanding Service




     ...
Consumers Seeking Knowledge and Information
Via Web Resources




                           6
Consumers Seeking Knowledge, Information, and Services
Via Websites Marketing Direct to the Consumer




                 ...
Consumers Seeking Information – Via Websites Marketing
Genotyping, Record Storage, Genetic Counseling

                   ...
Medical Travel

     Medical Tourism: “process of “leaving home” for treatments and
     care abroad or elsewhere domestic...
Primary Reasons for Medical Travel
              Driver*                                                               Exp...
Shared Concerns to Improve Patient Experience




                        Improving and measuring quality and
            ...
Balancing Act

  Balancing Act, InsideHealthcare (formerly HealthExecutive),
  September 2008
  − Employment alone will no...
IHI Framework for Engaging Physicians in Quality and Safety

          Discover Common Purpose
                           ...
Focus:             What strategies are being used to
                    strengthen physician-hospital alignment,
        ...
What Satisfies Physicians?

  #1 priority: how the administration responds to the
  ideas and needs of physicians
  4 of 5...
Physician Employment Trends

     Healthcare Industry is consolidating rapidly while significant
     physician shortages ...
The What and Why of P4P
What is P4P…
A program for aligning incentives to support the delivery of high-quality care
   Gov...
Providers Will Have to “Earn” What They Make….
 Medicare’s Shifting Priorities and Other Payers Seeking Value


          ...
Top Trends #2: Budgets will be Trimmed and Capital
               Investments Delayed

  Margins will decline
  The econom...
In Uncertain Economic Times, Strong Financial Performance
 Is Crucial

      With healthcare industry credit ratings decli...
Economic Crisis: Impact on Hospitals

          AHA Report on Impact of
          Economic Downturn on
          Patients ...
Subprime Mortgage Crisis Creates Perfect Storm for Tax-Exempt
Bond Auction Market

                              Tax-exemp...
The Capital Crisis

The availability of capital is generally limited and uncertain, but the need for capital
The availabil...
Prior to Recent Economic Crisis:
Factors Driving the Boom in Hospital Construction

      At the end of 2005, construction...
Need for Capital Will Continue

                    In March 2007, Wall Street Journal article stated that $200 Billion wi...
Organizations Will Need to Consider a Variety of Options to
Finance Construction

                How Organizations Are Fi...
Top Trend #3: The Industry Will Consolidate Even Further

 Hospitals that have historically relied on investment income, m...
ANK ‘s
DATAB itals
       sp
557 Ho a 3rd
        d
 reporte tal
   QTR to rgin
       n g ma
operati 6%)
    of (1.
     ...
Uncertainty: Impact of Economy on Total Margin in 2009
              Economy?
                  There are “winners” and “l...
And Many Hospitals Are Not Surviving – A Few Examples

     Since 1992 a total of 24 hospitals in New Jersey closed and fi...
What Steps are Hospitals Taking to Avoid Closure
                                                                    Did N...
In a Nut Shell




                                 Limited Options
 No More Money   No Super Hero
                       ...
Top Trend #4: The Workforce Will Be in Transition

 Physician responses to their own financial uncertainties will vary

 T...
Physician Responses to Their Own Financial Uncertainties will
Vary
     As many as 2/3 of workers
     As many as 2/3 of w...
Declining Utilization – Little Relief for the Current Shortage

    Physician Shortage is a Result of Both Increasing
    ...
Part-time Medicine and Nursing while Popular May Provide Relief

 Between 2005 and 2007, there was a 46% increase         ...
A Shift in the Mix of Care Providers with Greater Use of Mid-
Levels – Constraints on Medical Education will Force Changes...
Greater Use of Mid-Levels Driven by Many Factors
PAs, NPs, and Dr. Nurse – Should Help In Filling a Growing Gap

     The ...
Outlook for Nursing Gets Brighter

      After a net loss of more than 10,500 nurses in 2004 and 2005,
      we are now se...
Nursing Vacancies May Lessen Somewhat During the Downturn

     As reported in the WSJ, Jane Llewellyn, vice president of ...
Union Activity will Increase

        With a new administration favorable to Unions coupled with significant layoffs in jo...
Top Trend #5: Health Reform Will Not be Universal;
              But it Will be Everywhere

 Health reform will be a high ...
Reform as a National Priority: Stars are Aligning

                                                                 Altman...
Reform Initiatives on Many Fronts

                        Economy first priority. Connect improving economy with health r...
Proposed Principles for Payment Reform

The HFMA report proposes five basic principles for reform:

                      ...
Health Reform in Massachusetts

      Significant recognition as a model for reform
      “Near Universal” coverage “rough...
Preventive Care – Medicare Demonstration Projects

    Name                            Description                        ...
Episode of Care Payment – Medicare Demonstration Projects


   Medicare Participating Heart Bypass Demonstration Project (...
Episode of Care Payment – Private Sector Pilots


              Geisinger Health System – ProvenCareSM System

   Geisinge...
Noblis Center for Health Innovation – Top Trends for 2009
              Changing Consumer Demands
 Utilization will be sta...
Center for Health Innovation at a Glance

                                                    SERVICES
STAFF LOCATIONS
   ...
An Innovative Company Producing Enduring Positive Impacts

   Nationally recognized science, technology, and strategy orga...
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Top Trends For 2009 Noblis Webinar Presentation

  1. 1. Top Trends for 2009 Webinar: December 9 and 18, 2008 Presented by: Peggy Cella Amy MacNulty Senior Principal Senior Principal Peggy.cella@noblis.org amy.macnulty@noblis.org 678.728.6747 781.482.4072 Center for Health Innovation © 2008 Noblis, Inc.
  2. 2. Noblis Center for Health Innovation – Top Trends for 2009 Changing Consumer Demands Budgets Trimmed - Investments Delayed Continued Consolidation Workforce in Transition Health Reform on Many Levels quot;The future will be determined in part by happenings that it is impossible to quot;The future will be determined in part by happenings that it is impossible to foresee; it will also be influenced by trends that are now existent and observable.quot; foresee; it will also be influenced by trends that are now existent and observable.quot; Emily G. Balch -- American economist and sociologist. Honorary president of the Women's International League for Emily G. Balch American economist and sociologist. Honorary president of the Women's International League for Peace. Peace. 1
  3. 3. Top Trend #1: Consumer Demands will Continue to Change Utilization Trends will be stable or even decline in all but strongly growing markets Consumer will continue to seek medical information/knowledge via Web resources Increased Medical Travel Hospitals and physicians that continue to focus on improving and measuring quality, safety, and operating efficiencies will be best positioned for the future 2
  4. 4. Despite Historical Trends – Utilization will Be Stable or Decline in All But Strongly Growing Markets US Population (298.8M) grew by 16% Discharges (39.5M) grew by 28% Between 1993 and Discharge/1,000 population (116.9) declined by 3% 2006 ALOS (4.8) declined by 20% led by largest decline in 65 &> population (to 5.5 having declined by 29%) Discharges to Home Health grew by 53% Medicaid discharges grew by 36% Between 1997 and Medicare discharges grew by 17% 2006 No change in private insurance discharges Share of admissions through EDs increased from 38% to 44% 3
  5. 5. Once Thought to Be Recession Proof – Health Care is Feeling the Effect of the Downturn HCA with 160 hospitals reported flat HCA with 160 hospitals reported flat A survey of 112 nonprofit hospitals found that A survey of 112 nonprofit hospitals found that AHA 2008 Survey of admissions for the three months admissions for the three months overall inpatient admissions were down 2 to 3 overall inpatient admissions were down 2 to 3 more than 700 CEOs in ended 9/20/08 compared to the percent compared with a year earlier. More than ended 9/20/08 compared to the percent compared with a year earlier. More than late 2008 reported that 60 percent reported flat or declining admissions. previous year. 60 percent reported flat or declining admissions. previous year. 31% of hospitals September 2008 Survey by Citi Investment September 2008 Survey by Citi Investment surveyed had experienced a decrease “The possibility of putting off an expensive “The possibility of putting off an expensive The University of Pittsburgh Medical Center The University of Pittsburgh Medical Center surgery or other major procedure has not surgery or other major procedure has not in elective procedures in has not seen a drop in patient admissions but has not seen a drop in patient admissions but become a frequent topic of conversation become a frequent topic of conversation the past three months. reports that growth is tailing off. with patients.” reports that growth is tailing off. with patients.” Robert A DeMichiee, CFO Robert A DeMichiee, CFO In addition, 38% of Dr. Ted Epperly, family practice Boise, Idaho Dr. Ted Epperly, family practice Boise, Idaho hospitals surveyed Shands Health Care cited the poor Shands Health Care cited the poor reported a decrease in Hospital admission growth for Hospitals in Hospital admission growth for Hospitals in economy and lower patient demand economy and lower patient demand admissions during the the State of Florida in 2007 was the lowest in the State of Florida in 2007 was the lowest in when it announced in October that it same period. when it announced in October that it years with a growth of only 0.4%, accounting years with a growth of only 0.4%, accounting would shutter one of its eight hospitals. would shutter one of its eight hospitals. for just over 9,000 new admissions in the for just over 9,000 new admissions in the DATABANK’s entire state. entire state. preliminary 3rd quarter 2008 data (557 “More than half of chronically ill patients in the “More than half of chronically ill patients in the hospitals) reported 3rd U.S. reported at least one cost-related access U.S. reported at least one cost-related access “The numbers are down in the “The numbers are down in the quarter patient visits problem, such as not filling prescriptions, problem, such as not filling prescriptions, past month, there’s no question past month, there’s no question (discharges, surgeries, skipping doses, not visiting a physician when skipping doses, not visiting a physician when about it.” about it.” ED visits) as flat or sick, or not getting recommended care. sick, or not getting recommended care. declining relative to the Health Affairs, doi: 10.1377/hlthaff.28.1.w1(Survey conducted Health Affairs, doi: 10.1377/hlthaff.28.1.w1(Survey conducted Dr. Richard Friedman, Beth Israel Medical Dr. Richard Friedman, Beth Israel Medical in 2008 and Published online November 13, 2008) in 2008 and Published online November 13, 2008) same quarter of 2007. Center Center Source: “Hospitals See Drop in Paying Patients, NY Times, November 6, 2008; Modern Healthcare’s Daily Dose, November 13, 2008, FHA Eye on the Market: Hospital Utilization Report, October 2008. AHA Report on the Economic Crisis: Initial Impact on hospitals, November 2008. DATABANK is a licensed product of the Colorado Hospital Association. 4
  6. 6. Consumers Will Continue to Redefine Value to Include Communication, Information, Access, and Outstanding Service During Before After What Patients/Families Expect in Inpatient & Outpatient Care Timely Ease of navigation Same day reports appointments/ Minimum uncertainty/ Painless billing short wait times worry A “fair” price Convenient access Communication Confidence in excellence of care Source: “Many Americans open to care at retail-based health clinics,” Wall Street Journal, October 26, 2005; “For these startups, patients are a virtue,” San Francisco Chronicle, October 2, 2007 and Harris Poll Shows Number of quot;Cyberchondriacs,“ Harris Interactive website (July 31, 2007). 5
  7. 7. Consumers Seeking Knowledge and Information Via Web Resources 6
  8. 8. Consumers Seeking Knowledge, Information, and Services Via Websites Marketing Direct to the Consumer Patientsville.com - Your #1 Source for all the latest prescription and off-the-shelf medications side effect information. A Health Expert wants to answer your question. “Pinnacle Care takes the notion of VIP services to a whole new level” Washington Post Waterfront Media To Merge With Revolution Health Network Establishing The Everyday Health Network As The Preeminent Online Health Destination 7
  9. 9. Consumers Seeking Information – Via Websites Marketing Genotyping, Record Storage, Genetic Counseling deCODEme is an anonymous deCODEme is an anonymous information service. It is not a medical information service. It is not a medical service, nor a genetic test, and it is service, nor a genetic test, and it is not designed for medical decision not designed for medical decision making. Therefore it is not covered by making. Therefore it is not covered by health insurance companies. health insurance companies. 1. Order a kit ($399 USD) 2.Claim your kit, spit into the 3.CLIA-certified lab analyzes 4.Log in and start exploring your tube, and send it to the lab. your DNA in 4-6 weeks genome. 8
  10. 10. Medical Travel Medical Tourism: “process of “leaving home” for treatments and care abroad or elsewhere domestically” Deloitte 2008 Survey of 3,000 Americans: − 2007 estimated 750,000 Americans traveled abroad, projected to increase to 6 million in 2010 Turkey − “expected to experience explosive growth over next 3-5 year Check your Midnight − “Outbound” - 39% would go abroad for elective procedure to Express stereotypes at the door - this is a rapidly save money modernizing country with Gen Y 51.1%, Boomers 36.7%, Seniors 29.1% one foot in Europe and one in the Middle East. Medical Tourism Association – Three Tenets: It's not all oriental − Transparency, Communication and Education splendor, mystery, intrigue and whirling − 2nd World Medical Tourism & Global Health Congress dervishes but it is a spicy October 26th – 28th, 2009 in Los Angeles, CA California maelstrom of history knocking up against a Medical Tourism Facilitators pacy present. Source: Medical Tourism, Consumers in Search of Value, The Deloitte 2008 Survey of Health Care Consumers, Deloitte Center for Health Solutions. 9
  11. 11. Primary Reasons for Medical Travel Driver* Explanation Cost of procedure is much less than in the patient’s home country (e.g., Cost Savings United States). Waiting times for procedure can be much longer in home country, Improved Access especially for those with National Health Insurance or Health Service, such as Canada or the United Kingdom. Certain medical procedures are still considered experimental, not yet Procedure Not Available approved, or in clinical trials in the patient’s home country. Some patients value the exotic destinations or luxurious Tourism/Vacations accommodations in the destination country. Privacy and Some patients (especially celebrities) may be concerned about their Confidentiality privacy if the procedure is performed in their home country. Wellpoint soon will offer some medical travel benefits Starting in January, Wellpoint will offer employees of Wisconsin-based Serigraph Inc. the option of traveling to India for nonemergency procedures such as joint replacement surgery. Serigraph will waive the insurance deductible and coinsurance for employees who agree to go, paying all medical costs as well as travel expenses for the patient and a companion. quot;This is a leap of faith, obviously, to say if you go to India, we'll pay for the whole shebang,quot; said Linda Buntrock, Serigraph's senior vice president of human resources. quot;But the cost difference is so monumental.“ Knee replacement surgery that costs between $60,000 and $70,000 in the United States can be done in India for $8,000 to $10,000, said Jill Becher, a Wellpoint spokeswoman. Source: CHEN MAY YEE, Star Tribune,November 13, 2008 * Source: “Medical Travel – Threat or Opportunity for U.S. Providers? It Depends on Your Perspective”, J. Vitalis and G. Milton, Horizons: Journal of the Center for Health Innovation, Winter 2009. 10
  12. 12. Shared Concerns to Improve Patient Experience Improving and measuring quality and safety Physician Concerns Hospital Concerns Achieving operating efficiencies Creating a positive work environment Bridging Generational differences Leveraging capabilities with medical technologies Fostering alternative care settings to improve access (walk-in clinics) 11
  13. 13. Balancing Act Balancing Act, InsideHealthcare (formerly HealthExecutive), September 2008 − Employment alone will not achieve alignment − Early involvement in decision making critical to alignment − Key areas of engagement: Improve the quality of services and clinical outcomes, ensuring consistent excellence across the system. Strengthen collaboration among physicians on the medical staffs to enhance their understanding of the qualities and skills of their colleagues and improve communication and patient care. Enhance physician leadership development efforts to build a strong core of physicians who can determine future success requirements, ably represent their peers, and collaborate effectively with hospital AHA Economic Crisis Report, Nov. 2008 reported that 56% of hospitals experienced an increase in physicians seeking financial support from hospitals and % physicians seeking: − 83% - increased payment for on-call or other services − 69% - employment − 31% - to sell their practice − 23% - to partner on equipment purchase 12
  14. 14. IHI Framework for Engaging Physicians in Quality and Safety Discover Common Purpose “To bring these two worlds Reframe Values and Beliefs into alignment, both parties have to be interested in Segment the Engagement Plan making good-faith efforts to understand each other’s Use “Engaging” Improvement Methods point of view and needs.” Show Courage Source: Healthcare Executive, Medical Staff Source: Healthcare Executive, Medical Staff Collaboration, Communication Strategies that Get Collaboration, Communication Strategies that Get Results, July/Aug 2006 Results, July/Aug 2006 Adopt an Engaging Style Source: IHI Innovation Series 2007, Engaging Physicians in a Shared Quality Agenda, J. Reinertsen, MD, A.Gosfield, JD, W. Rupp, MD, J. Whittington, MD. 13
  15. 15. Focus: What strategies are being used to strengthen physician-hospital alignment, and which strategies are most effective? Hospital Perspective Physician Perspective Disconnect between Similar leadership leadership and practicing disconnect physicians Information systems critical Of the 10 most effective strategies, half involved employing physicians Source: Noblis/AHA, Strategies for Strengthening Physician-Hospital Alignment: A National Study, 2006; ACPE Member Survey 2008 14 14
  16. 16. What Satisfies Physicians? #1 priority: how the administration responds to the ideas and needs of physicians 4 of 5 top priorities deal directly with doctors’ relationships with administrators One way the administration can build their relationships with physicians is to make it easier for doctors to care for their patients Physicians are most satisfied with hospitals in their first 5 years and after 20 years on staff Physicians employed by the hospital are more satisfied than non- employed physicians 2008 Press Ganey Hospital Check-Up Report - Physician Perspectives on 2008 Press Ganey Hospital Check-Up Report - Physician Perspectives on American Hospitals American Hospitals 15
  17. 17. Physician Employment Trends Healthcare Industry is consolidating rapidly while significant physician shortages are projected − Substantial economic advantages for systems that integrate payers, hospitals and physicians New wave of employment different than late ’80s and early ’90s: − Primary care and specialty physicians − Willingness to trade off autonomy for economic security − “Cornerstone strategy” for large integrated systems, e.g., Aurora, WI, Advocote, IL, Senatara, VA − Many hospitals and health systems find themselves with no other choice, need to view as “fundamental strategic asset” − Payers shifting to “Pay for Performance” and “Medical Homes” − New generation of physicians seeking improved work/life balance − Greater emphasis on developing physician leadership and systemized physician engagement “This is the beginning of a fundamental restructuring of how “This is the beginning of a fundamental restructuring of how physicians function in the health care system.” physicians function in the health care system.” William Jessee, MD, President of the Medical Group Management Association. William Jessee, MD, President of the Medical Group Management Association. Source: “Employing Physicians”, D. Beckham, HHN, 9/07 16
  18. 18. The What and Why of P4P What is P4P… A program for aligning incentives to support the delivery of high-quality care Government-sponsored projects—Annual Payment Update (APU), Premier demo, MedPac recommendation, Value-Based Purchasing (VBP), Physician Group Practice (PGP) demo, State Medicaid Programs Private payer initiatives (LeapFrog Group, Bridges to Excellence, IHA, individual insurers) Why P4P… CMS: “The right care for every person every time” Imperative to improve quality Institute of Medicine (IOM) reported that 98,000 lives lost due to medical errors Public reporting of health care organization performance Institute for Health Improvement (IHI) 100,000 Lives Campaign (and now 5 Million Lives Campaign) Imperative to control costs Consumer-driven focus on reducing their out-of-pocket costs for health care Employer focus on reducing health care insurance costs 17
  19. 19. Providers Will Have to “Earn” What They Make…. Medicare’s Shifting Priorities and Other Payers Seeking Value Change Effect Coding for Severity of Illness Eliminates Skew Toward Less Complicated Cases Cost-Based Weights Equitable Reimbursement for Cost of Care Overhauling of ASC Payments Alters the Competitive Landscape P4P & Never Events Emphasizes Safety and Quality of Care Bundled Payments Rewards improvements in quality of care and efficiency Source: “HFMA’s Healthcare Finance Outlook,” HFMA, January 2007 and 2008. 18
  20. 20. Top Trends #2: Budgets will be Trimmed and Capital Investments Delayed Margins will decline The economic downturn will force most hospitals to trim their operating budgets in 2009. The credit market will tighten further and bond ratings will fall. Great pressure will exist to maintain cash on the balance sheet. New technology capital expenditures that do not meet quality and safety mandates or do not improve the bottom line in the short term will be delayed, scaled back, or cancelled. The recent health care construction boom will continue but at a much slower rate. 19
  21. 21. In Uncertain Economic Times, Strong Financial Performance Is Crucial With healthcare industry credit ratings declining for a majority of the past decade, it will be increasingly important for hospitals to maintain a strong financial performance − Hospitals with strong financial performance and good credit will have a much easier time accessing capital and bond insurance Hospitals should focus on two key measures of financial performance Measure Target Reason Patient Care Margin Greater than 0.0 percent If hospital cannot earn profit on patient care services, it must rely on non-patient care sources of funding EBITDA Margin At least 4.0 percent Minimum level of profit needed to re-invest in capital expenditures Source: “The outlook for capital access and spending,” HFMA, August 2006; “Hospital insolvency: the looming crisis,” Alvarez & Marsal, March 2008 20
  22. 22. Economic Crisis: Impact on Hospitals AHA Report on Impact of Economic Downturn on Patients and Hospitals, 11/19/08 Survey of 736 hospitals and DATABANK a web-based hospital reporting system used in 30 states 30% reported moderate to significant decline in patients seeking elective procedures 40% reported drop in admissions overall Uncompensated care up 8% from July to September vs. same period last year. Negative 1.6% total margins in 3rd quarter of 2008 vs. positive Hospitals feel the pain of recession 6.1% same quarter last year. By Richard Pizzi, Editor , 11/01/08 Investment losses…. As economy slows, tax receipts Cutback made or considered: − Administrative costs (60%) decrease both at federal and state − Reducing staff (53%) levels. − Reducing services (27%) All states will have issues, some hit harder than other: Florida and Interests payments increased on average by 15% California some of the hardest hit. Facility investments reconsidered or postponed − Plans to increase capacity (56%) Survival in economic downturn will − Delay purchase of clinical technology or equipment (45%) depend on gaining operational − Put off investments in new IT (39%) efficiency in the near time. 21
  23. 23. Subprime Mortgage Crisis Creates Perfect Storm for Tax-Exempt Bond Auction Market Tax-exempt rates are likely to be higher Rating agencies to use more stringent assumptions Debt must be increasingly collateralized and/or backed by bank letters of credit Lessons learned: − Incorporate assumptions about tighter markets and volatile interest rates − Update projections done to support projects in recent years − Expect more focus on the underlying credit of borrower − Diversify financing sources to minimize cost at an acceptable level of risk − For strong credits, may make sense to refund and go forward without insurance cost or to buyback debt in short-term and refinance later Source: Deborah Kolb-Collier, Scott Clay, and Peter Bruton, “What Hospital Systems Can Do to Ride Out the Financial Market Turbulence,” HealthLeaders Media, March 17, 2008; “The credit crunch squeezes municipal bonds,” U.S. News, February 28, 2008. 22
  24. 24. The Capital Crisis The availability of capital is generally limited and uncertain, but the need for capital The availability of capital is generally limited and uncertain, but the need for capital is constant and seemingly boundless. is constant and seemingly boundless. Capital Availability Capital Needs Construction of new health About one-quarter of all care facilities expected to community hospitals reach $60 billion by 2010. continue to operate “in the red.” Most CFOs expect their Negative patient margins hospital’s capital spending are being supplemented by to increase in the next 4 other sources (e.g., years. The top 3 most investment income, commonly cited capital philanthropy, etc.). projects all focused on IT: The capital markets view - Digital Radiology Systems healthcare with increasing - CPOE Systems scrutiny. - Major IT Systems Sources: The Lewin Group Analysis of the American Hospital Association Annual Survey data, 1991 – 2004. Baltimore Business Journal, “Rx for Hospital Design,” January 19, 2007. FutureScan Healthcare Trends and Implications, 2005 – 2010. 23
  25. 25. Prior to Recent Economic Crisis: Factors Driving the Boom in Hospital Construction At the end of 2005, construction of Key Drivers new hospitals and clinics was valued Aging facilities at $22 billion Increasing patient By 2010, construction of new volumes healthcare facilities expected to reach $60 billion New technology Need for single rooms Percentage of Hospital’s Capital Budget Allocated to Construction Projects in 2008 (Projected) Changing patient populations Increasing competition 24% New Construction Hospital-physician alignment Facility 51% Modernization Consumerism Other 25% Source: “Healthcare construction and capital implications,” HFMA, February 2008; “Health construction rolls right along,” H&HN, March 2008. 24
  26. 26. Need for Capital Will Continue In March 2007, Wall Street Journal article stated that $200 Billion will be spent on rebuilding or replacing aging hospitals over the next decade. What now? Short-Term Focus Median Average Age of Plant 1990 - 2006 Delay implementing 12 master plans 9.7 9.8 9.8 9.8 9.9 9.7 9.2 9.4 10 9.3 8.9 9.2 8.6 8.8 8.4 Essential renovations 7.9 8.0 8.2 8 and technology 6 Maximize capacity with improved efficiency 4 Longer horizon for 2 most projects 0 Re-phasing and re- 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 prioritizing Source: The Almanac of Hospital and Financial Operating Indicators, 1994, 1997, 2006, 2008 25
  27. 27. Organizations Will Need to Consider a Variety of Options to Finance Construction How Organizations Are Financing Construction Projects 46% 33% 29% 28% 21% Existing Cash Tax-Exempt Operations Philanthropy Other Debt Reserves Bonds Source: “Health construction rolls right along,” H&HN, March 2008. 26
  28. 28. Top Trend #3: The Industry Will Consolidate Even Further Hospitals that have historically relied on investment income, municipal funding of indigent and charity care, and low interest rate credit lines to offset operating losses will be hardest hit Small hospitals and rural hospitals are most at risk in a downturned economy 27
  29. 29. ANK ‘s DATAB itals sp 557 Ho a 3rd d reporte tal QTR to rgin n g ma operati 6%) of (1. red to compa e 3rd r th 6.1% f o 07 QTR ’ Financial challenges again ranked as the top concern for hospital chief executive officers, according to a yearly survey by the American College of Healthcare Executives. Providing care to uninsured patients placed second, followed by hospitals’ relationships with physicians, according to the survey results. DATABANK also report ed an 8% increase in (January 7, 2008) uncompen sated care for the sam e period. Source: AHA, Report on the Economic Crisis: Initial Impact on Hospitals, November 2008 (Callouts). Note: DATABANK is a licensed product of the Colorado Hospital Association. 28
  30. 30. Uncertainty: Impact of Economy on Total Margin in 2009 Economy? There are “winners” and “losers” in every kind of market Industry Perspective U.S. Hospital – Total Margin 10.0% What model will work in 2009? 8.0% 6.0% 4.0% 2.0% 0.0% -2.0% 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 75th Percentile Median 25th Percentile Source: “Almanac of Hospital Financial and Operating Indicators,” Ingenix, 1998-2007. 29
  31. 31. And Many Hospitals Are Not Surviving – A Few Examples Since 1992 a total of 24 hospitals in New Jersey closed and five hospitals filed for bankruptcy protection in less than two years. − The New Jersey Hospital Association reported that nearly half of the state’s hospitals posted losses, three hospitals closed, and five filed for bankruptcy in 2007. − In the first eight months of 2008, five more hospitals in New Jersey closed. The Pennsylvania Health Care Cost Containment Council report identified that 24 percent of the 170 general acute care hospitals stateside lost money in 2007. In a ten day period in August of this year, at least 10 hospitals closed or filed for bankruptcy protection. Date Hospital Status Muhlenberg Regional Medical Center Ceased all inpatient services citing mounting financial losses in the face of August 13, 2008 Plainfield, NJ decreased federal and state funding Trinity Hospital Competing bids for assets from Restoration Health Care, Erin, Tennessee, August 19, 2008 Erin, Tennessee and a subsidiary of Rural Healthcare Developers, Plantersville, MS August 21, 2008 Renaissance Hospitals (5 Hospitals) Filed Chapter 11, cost overruns and the collapse of capital markets drained August 26, 2008 Texas the system’s resources Century City Hospital Medical Center August 22, 2008 Closed on August 27, 2008 Los Angeles, CA North Oakland Medical Center August 26, 2008 Proposed sale to newly formed physician-owned for-profit company Pontiac, Michigan Hawaii Medical Center August 29, 2008 Restructuring, seeking to emerge from bankruptcy Honolulu, Hawaii Source: Modern Healthcare reporting. Modern Healthcare, September 22, 2008, page 10.The Birmingham, News, October 23, 2008; Chicago Tribune, September, 20, 2008, NorthJersey.com, November 25, 2008; Pittsburgh Business Times, April 18, 2008; 2008 Update: The Crisis Deepens, new Jersey Hospital Association,. 30
  32. 32. What Steps are Hospitals Taking to Avoid Closure Did NY State get Did NY State get it right by it right by Staying on top of finances proactively proactively − Delaying capital projects and equipment purchases addressing addressing − Targeting cash flow efforts overbedding and overbedding and − Converting indigent to Medicaid payment – but will access in their 2006 access in their 2006 Recommendations Recommendations State coffers support the expected increased demand? to reform Hospitals to reform Hospitals − Aggressively managing bad debt and Nursing and Nursing − Auctioning hospital debt Homes? Homes? Staff Reductions – Few Hospitals have avoided some staff reductions this year − Freezing vacancies − Layoffs – initial efforts targeted to avoiding direct care/nursing positions − Leaner management level Service discontinuation/reduction Lobbying legislature to protect Medicare/Medicaid payments Exploring merger/consolidation options 31
  33. 33. In a Nut Shell Limited Options No More Money No Super Hero MERGER 32
  34. 34. Top Trend #4: The Workforce Will Be in Transition Physician responses to their own financial uncertainties will vary There will be a shift in the mix of care providers with greater use of mid- levels Nursing vacancies may lessen somewhat Union activity will increase 33
  35. 35. Physician Responses to Their Own Financial Uncertainties will Vary As many as 2/3 of workers As many as 2/3 of workers may delay retirement due to may delay retirement due to According to a 2007 Merritt Hawkins Survey: According to a 2007 Merritt Hawkins Survey: the downturn in the economy the downturn in the economy 49% of physicians aged 51+ years indicated that 49% of physicians aged 51+ years indicated that they plan to make a change in their practice in the they plan to make a change in their practice in the Physician next one to three years next one to three years Population is Plan to retire 14% Aging Plan to retire 14% Plan to seek a medical job in a 7% Plan to seek a medical job in a 7% 47% of 47% of non-clinical setting non-clinical setting physicians are physicians are Plan to seek a job or business 3% Plan to seek a job or business 3% over age 50 over age 50 in a non-medical field in a non-medical field Plan to work on a temporary basis 4% Plan to work on a temporary basis 4% 36% of 36% of Plan to work part-time 7% Plan to work part-time 7% physicians are physicians are Plan to close their practice to new 8% Plan to close their practice to new 8% 65 or older 65 or older patients patients Plan on taking a combination of the 7% Plan on taking a combination of the 7% above steps above steps Source: 2007 Survey of Physicians 50 to 65 Years of Age, Merritt Hawkins & Associates, 2007 34
  36. 36. Declining Utilization – Little Relief for the Current Shortage Physician Shortage is a Result of Both Increasing Demand and Shrinking Supply Increasing Demand Shrinking Supply Aging population Aging physician Physician Physician workforce Shortage Shortage Growing population Changes in practice patterns Longer life spans Education system constraints Prevalence of Need for chronic disease Physician Workforce Planning 35 35
  37. 37. Part-time Medicine and Nursing while Popular May Provide Relief Between 2005 and 2007, there was a 46% increase Women represent in the number of physicians working part-time 50 percent of US medical students % of All Physicians Practicing Part-time 18.1% 17.2% 14.5% 14.5% 14.0% 13.1% 24% of female physicians of age 8.6% less than 50 years 7.6% work part-time vs. 2% of male 29 or 30 – 34 35 – 39 40 – 44 45 – 49 50 – 54 55 – 59 60+ physicians less Age Groups MEN – Unrelated professional or personal pursuits Top Reason to Work Part-time WOMEN – Family responsibilities (including pregnancy) Source: 2007 Physician Retention Study, Cejka Search and AMGA; “Will There be Enough Doctors”, HealthLeaders, October 2007. 36
  38. 38. A Shift in the Mix of Care Providers with Greater Use of Mid- Levels – Constraints on Medical Education will Force Changes Qualified applicants continue to far outnumber available slots. While the American Association of Medical Colleges has called for an increase in Medical School enrollment of 30 percent (approx. 5,000 more each year), even if achieved, will take 11 years before number of practicing MDs will increase. Residency program caps continue to pose a problem. U.S. Medical School Applicants & Graduates 50,000 40,000 30,000 Applicants 20,000 Graduates 10,000 0 1995 1995 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Source: AAMC Statement on the Physician Workforce, June 2006. Data Warehouse: Applicant Matriculant File as of 10/27/06, 2008 aamc.org 5/12/08. http://www.naahp.org/PDFs/HealthProfPDFs/AAMC.pdf. 37
  39. 39. Greater Use of Mid-Levels Driven by Many Factors PAs, NPs, and Dr. Nurse – Should Help In Filling a Growing Gap The supply of Physician Assistants is projected to increase by up to 50% over the next decade potentially partially filling the ever widening gap in primary care. The primary care physician shortage has rapidly increased interest and planning for a new kind of “mid-level” - The “Dr. Nurse”. − More than 200 nursing schools are in some level of planning or development of a “doctorate of nursing practice” - to equip graduates that some schools say are equivalent to primary care physicians. − Advanced practice nurses with national certification in an advanced practice nursing specialty, and a Doctor of Nursing Practice degree, are eligible to sit for certification. The exam is derived from the test pool of the USMLE Step 3 exam for MD licensure candidates. Successful DNP candidates will be designated as Diplomats in Comprehensive Care by the newly established American Board of Comprehensive Care. Sources: AAPA website, http://www.aapa.org/research/index.html; Wall Street Journal, April 2, 2008, HealthLeaders, Making room for ‘Dr. Nurse’, December 2, 2008 38
  40. 40. Outlook for Nursing Gets Brighter After a net loss of more than 10,500 nurses in 2004 and 2005, we are now seeing gains in nurse workforce. The recent economic downturn and rocky housing market are driving nurses into the workforce . Despite recent increase in nurses, projected gap in supply and demand remains. Despite these gains, the American Association of College of Nursing reported growth in new enrollment at undergraduate nursing programs stagnated in 2008, while growth in graduate nursing and research doctorate programs either slowed to a crawl or did not show any growth. Nurses Added to the Healthcare Workforce Projected Shortage of Nurses in 2020 2003 vs. 2008 84,200 765,000 285,000 18,700 2003 2008 2006 2007 Source: “The nurse staffing outlook gets brighter,” Modern Healthcare, May 1, 2008. 39
  41. 41. Nursing Vacancies May Lessen Somewhat During the Downturn As reported in the WSJ, Jane Llewellyn, vice president of clinical nursing affairs at Rush University Medical Center in Chicago, said, quot;We are seeing a temporary lessening of the nursing shortage,quot; but, quot;as soon as the economy turns up, we'll see them staying home again.quot; The Washington Post examined how hospitals across the U.S. have begun addressing nursing shortages quot;by introducing technology to dramatically reduce paperwork, offering more flexible hours, reducing caseloads, paying for advanced training and giving [nurses] more authorityquot; instead of using financial incentives to lure nurses. In 2007, the number of open nursing jobs in the U.S. reached 116,000. Although the vacancy rate has dropped slightly because of the quot;dismal economyquot; – nurses are working longer hours to make up for unemployed spouses, according to the Post – hospitals are quot;bracing for 2025 when retirements and other factors are projected to push the number of open jobs to as many as one million, just when Baby Boomers will require more nursing care,quot; the Post reports. Source: Kaiser Daily Health Policy Report Hospitals Offering Better Working Conditions Instead of Financial Incentives To Address Nursing Shortages. September 15, 2008. Wall Street Journal, Economic Downturn Prompts Many Nurses To Work More Shifts, Helps Address Nursing Shortage. May 07, 2008 . 40
  42. 42. Union Activity will Increase With a new administration favorable to Unions coupled with significant layoffs in jobs most effected by the downturn, efforts to unionize health care workers are expected to increase. − The Employee Free Choice Act of 2007, co-sponsored by Obama, would require employers to recognize unions if a majority of employees sign union-authorized cards. The bill was blocked in the Senate by Republicans. − Also expected to pass if reintroduced is the 2007 Re-Empowerment of Skilled and Professional Employees and Construction Trades Workers (RESPECT Act) was introduced in March 2007 by Democrats Senator Chris Dodd and Representative Rob Andrews. − Beneficial to unions, the free choice act would eliminate the 45-day election period in which employers can offer educational sessions to workers on the pros and cons of unions. The Sisters of St. Joseph of Orange are The Sisters of St. Joseph of Orange are quot;The results of this election quot;The results of this election By forming the national healthcare union, we will By forming the national healthcare union, we will clashing with a union that wants to will determine whether we'll clashing with a union that wants to will determine whether we'll become the recognized voice of front-line healthcare become the recognized voice of front-line healthcare organize at a chain of hospitals the nuns be able to grow the union organize at a chain of hospitals the nuns be able to grow the union workers everywhere, fueling our ability to help members workers everywhere, fueling our ability to help members for nurses or whether we'll operated throughout California. SEIU- for nurses or whether we'll operated throughout California. SEIU- win by uniting more and more workers in our union. be on the defensive. “ win by uniting more and more workers in our union. West hopes to unionize more than 8,000 be on the defensive. “ West hopes to unionize more than 8,000 Betsy Marville, RN Betsy Marville, RN caregivers, cafeteria works and X-ray caregivers, cafeteria works and X-ray SEIU Healthcare Website SEIU Healthcare Website SEIU Website SEIU Website technicians at five hospitals. technicians at five hospitals. “Hospitals are aware that unions have “Hospitals are aware that unions have “Nurses are excited that we have opportunities with the “Nurses are excited that we have opportunities with the targeted health care as fertile ground for Democrats in power. Issues related to workers’ rights and safety targeted health care as fertile ground for Democrats in power. Issues related to workers’ rights and safety all will be part of a more progressive agenda in this county”. all will be part of a more progressive agenda in this county”. organizing” organizing” John Carebian, Executive Director John Carebian, Executive Director Lori Latham, VEEP Michigan Health and Hospital Association Lori Latham, VEEP Michigan Health and Hospital Association Michigan Nurses Association Michigan Nurses Association Source: Crain’s Detroit Business, November 9, 2008. HealthLeaders Media August 8, 2008. SEIU website. 41
  43. 43. Top Trend #5: Health Reform Will Not be Universal; But it Will be Everywhere Health reform will be a high priority on a national level although significant national system reform is unlikely in the short term. Hospitals will increase efforts to fund care for their uninsured patients. 42
  44. 44. Reform as a National Priority: Stars are Aligning Altman’s Law Reform Challenges: “Most Every Constituent Group Supports First Step: Cost, Coverage or Both Some Form of National Health Insurance— But If Its Not Their Version of The Plan Coverage: Comprehensive or Universal Their Second Best Alternative Is To Maintain The Status Quo.” Insurance Plans: Private, Public or Both Stuart H. Altman, Heller School for Social Policy and Management, Brandeis University − Expand Medicare and/or Medicaid − Institute Government-Run Insurance Plan (Obama’s National Health Plan) Requirements: Employer Pay or Play, Individual Mandate Beyond Children Alignment of Payments to Health Goals − Prevention, Chronic Care, Outcomes, Quality, Value Top Down, Bottom Up, Both − Federal and State Initiatives Financing the Plan - $50b+ annually? 43
  45. 45. Reform Initiatives on Many Fronts Economy first priority. Connect improving economy with health reform. Greater public responsibility for health care. Many lessons learned from the past – need for compromise. Obama Policy Key Themes: 1) Improve access to care and coverage for all; 2) Control costs, and 3) Improve Quality. “Meaningful” coverage Baucus (D-MT) Higher quality/greater value Reduce waste Wyden (D-OR) The Healthy Americans Act Portable, affordable, high quality private health care guaranteed for all. Bennett (R-UT) Expected in January 2009, call for universal health care Kennedy (D-MA) Formation of 3 Senate working groups to align leadership Pelosi (D-CA) House Speaker has indicated plans to pass legislation requiring physicians nationwide to adopt HITs. Thomas A. Daschle, Obama’s choice for HHS Secretary. HHS accounts for one-quarter of all federal spending, HHS second only to defense. Daschle will take on expanded role to “shepherd” health reform legislation through Congress in 2009. “As CBO Director, Peter Orszag has practically been the ‘bionic man’ when Congress has needed budget guidance CBO Director to on everything from stimulating the economy to fixing health care. With all the economic challenges now facing the Head White country, there is no one better qualified than Peter Orszag to provide the solid numbers and sound advice that the House OMB president will need to solve the current crises and get our economic future on track.” Senators Wyden and Bennett Sources: Susan Berson, Esq. “ A Glimpse Into the Future: Predicting the Health Care Landscape in 2009”, Mintz Levin; “HHS Will be Shepherding Health-Care Reform”, washingtonpost.com, 12.5.08; Late News, Modern Healthcare, 12.1.08 44
  46. 46. Proposed Principles for Payment Reform The HFMA report proposes five basic principles for reform: Payments reward high-quality care and discourage medical Quality Quality errors and ineffective care. Payment incentives are aligned among all stakeholders to Alignment Alignment maximize the efficiency and coordination of health services. Payment systems sufficiently balance the needs and Fairness/ Fairness/ concerns of all stakeholders. Sustainability Sustainability Payment systems are simplified, standard, and transparent. Simplification Simplification The resources needed to support societal benefits of the Societal Societal healthcare system are identified and paid for explicitly. Benefit Benefit Source: Healthcare Payment Reform: From Principles to Action; Healthcare Financial Management Association, 2008. 45
  47. 47. Health Reform in Massachusetts Significant recognition as a model for reform “Near Universal” coverage “roughly 97% of MA residents are now covered”, lowest in the US Principals of Reform − Build upon the existing base: fill in gaps − “Shared responsibility” The Connector in Massachusetts: Individuals The “Travelocity” of Health Insurance Employers Government Indiv.& Families Section 125 plans − Shift financing from “opaque bulk Young Adults Small Biz. payments” to safety net providers to health insurance for individuals Individual Mandate − All adult residents − Minimum Creditable Coverage − Enforced through state tax system 2008 Penalties: $210 - $912 5 Sources: Nancy Trumbull, Professor, Harvard School of Public Health; “Mass. Model of healthcare reform, hurdles, boston.com, 11.6.08. 46
  48. 48. Preventive Care – Medicare Demonstration Projects Name Description Implemented Tests a variety of care coordination models to reduce hospitalizations, improve health status, and reduce Medicare overall healthcare costs for chronically ill Coordinated 2002 beneficiaries. Care Demonstration Fifteen organizations receive monthly fees to coordinate care and provide disease management. Provider-directed model to manage care of high-cost and high-risk beneficiaries including those with Care chronic conditions. Management for 2005 High-Cost CMS will test a variety of models including structured Beneficiaries chronic care programs, increased provider availability, and flexibility in site settings. Three-year medical home demo in up to 8 states Medicare which will pay care management fees to physicians Under Medical Home overseeing implementation of care plan for persons Development with multiple chronic illnesses. 47
  49. 49. Episode of Care Payment – Medicare Demonstration Projects Medicare Participating Heart Bypass Demonstration Project (1990s) Four hospitals (Ann Arbor, Atlanta, Boston, Columbus) each received a single payment covering hospital and physician services for CABG. Payments negotiated to be 10% - 37% below normal payment levels. All parties benefited: physicians reduced LOS and hospital costs, post- discharge costs (not included) also decreased, patients had only one co-pay. Medicare Acute Care Episode Demonstration (ACE) 2009 Five-year demonstration project to make global payments for hospital/ physician services for cardiac care (OHS, defibrillators, pacemakers, etc.) and orthopedic care (hip and knee replacements). One system in each market (Texas, Oklahoma, New Mexico, and Colorado) will be chosen based on price and quality/approach. 48
  50. 50. Episode of Care Payment – Private Sector Pilots Geisinger Health System – ProvenCareSM System Geisinger provides a “warranty” that covers any follow-up care needed for avoidable complications within 90 days at no additional charge. Currently used for CABG with plans to expand to hip replacement, cataract surgery, angioplasty and other areas. PROMETHEUS Payment, Inc. Currently developing episode of care payment system for a variety of conditions including AMI, hip and knee replacements, CABG, bariatric surgery, and hernias. Full episode of care payments for all providers will be based on actual historical cost and estimated costs using evidence-based care with adjustments based on quality performance. 49
  51. 51. Noblis Center for Health Innovation – Top Trends for 2009 Changing Consumer Demands Utilization will be stable or even decline in all but strongly growing markets. Consumers will continue to seek medical information/knowledge via web resources. Increased medical travel. Hospitals and physicians that continue to focus on improving and measuring quality, safety, and operating efficiencies will be best positioned for the future. Budgets Trimmed - Investments Delayed Margins will decline. The economic downturn will force most hospitals to trim their operating budgets in 2009. The credit market will tighten further and bond ratings will fall. Great pressure will exist to maintain cash on the balance sheet. New technology capital expenditures that do not improve the bottom line in the short term will be delayed, scaled back, or cancelled. The recent health care construction boom will continue but at a much slower rate. Continued Consolidation Hospitals that have historically relied on investment income, municipal funding of indigent and charity care, and low interest rate credit lines to offset operating loses will be hardest hit. Small hospitals and rural hospitals are most at risk in a downturned economy. Workforce in Transition Physician responses to their own financial uncertainties will vary. There will be a shift in the mix of care providers with greater use of mid-levels. Nursing vacancies may lessen somewhat. Union activity will increase. Health Reform on Many Levels Health reform will be a high priority on a national level although significant national system reform is unlikely in the short term. Hospitals will increase efforts to fund care for their uninsured patients. 50
  52. 52. Center for Health Innovation at a Glance SERVICES STAFF LOCATIONS Denver, CO Atlanta Area Strategy Development Service Line Planning 303.954.8644 (voice) 404.231.4422 (voice) Strategic and business plans Service line business plans and 312.751.8782 (fax) 404.231.4423 (fax) Strategic thinking facilitation structures Affiliation planning Demand/financial modeling Portland, OR Ann Arbor, MI Portfolio assessments Physician linkages Marketing plans & market assessments 312.751.4173 (voice) 734.944.7524 (voice) Financial Assessment 312.751.8782 (fax) 734.944. 7534 (fax) Governance Acquisition, divestiture & merger Defining governance roles analyses St. Louis, MO Austin, TX Governance structure and best practices Multi-year financial projections Board education and development Financial feasibility studies 512.784.8616 (voice) 314.726.4879 (voice) Determination of financial capability 512.301.9466 (fax) 314.721.8695 (fax) Regulatory Planning Capital allocation assistance CON/DON assistance Virginia Beach, VA Expert testimony Boston Area Performance Innovation 757.284.1177 (voice) Labor productivity 781.482.4050 (voice) Post-Acute Strategy 800.420.5295 (fax) Clinical resource management 781.863.5657 (fax) Strategic planning Margin improvement Operational improvement/turnaround Hospital acquired conditions avoidance Compliance Washington DC Area Chicago, IL Customer service/patient satisfaction 703.610.1001 (voice) Small hospital turnkey assessments Physician Strategy 312.751.8800 (voice) 703.610.2453 (fax) 312.751.8782 (fax) Physician-hospital alignment Facility Planning Medical staff development planning Master facility planning Physician practice/organization planning West Springfield, MA Cleveland, OH Concept of Operations Functional/operational space 216.789.0041 (voice) 413.732.3366 (voice) programming 216.932.1852 (fax) 413.732.7711 (fax) Capacity and throughput planning www.noblis.org http://www.noblis.org/hc/HealthInnovation.asp 51
  53. 53. An Innovative Company Producing Enduring Positive Impacts Nationally recognized science, technology, and strategy organization We are a 501(c)(3) with a Mission to serve the public good Our Vision is to create enduring positive impacts on our clients’ missions Some of our profits are reinvested into Noblis-sponsored research to address our Nation’s most complex problems We focus our resources on six areas of National importance National Environmental Security & Healthcare & Energy Intelligence Sustainability Oceans, Public Transportation Atmosphere, Safety & Space Noblis was named one of the “World’s Most Ethical Companies” for 2008 by the Ethisphere Institute Our Program Will Begin Momentarily © 2008 Noblis, Inc. 52
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