Hos­pi­tals should col­lab­o­rate, not com­pete, on pa­tient safety

Modern Healthcare - - Q & A -

Richard Umb­den­stock has served as pres­i­dent and CEO of the Amer­i­can Hos­pi­tal As­so­ci­a­tion since 2007.

His ca­reer in­cludes ex­pe­ri­ence in hos­pi­tal ad­min­is­tra­tion; health sys­tem gover­nance, man­age­ment and in­te­gra­tion; as­so­ci­a­tion gover­nance and man­age­ment; HMO gover­nance; and health­care gover­nance con­sult­ing. He is vice chair­man of the Na­tional Qual­ity Forum and serves on the board of En­roll Amer­ica. Mod­ern Health­care Ed­i­tor Mer­rill Goozner re­cently spoke with Umb­den­stock about the future of value-based pay­ment, nar­row net­works and an­titrust en­force­ment. This is an edited tran­script.

Mod­ern Health­care: What’s your re­ac­tion to the re­cent court de­ci­sion bar­ring Oba­macare pre­mium sub­si­dies in the fed­eral in­sur­ance ex­change?

Richard Umb­den­stock: We con­tinue to be sup­port­ive of peo­ple re­ceiv­ing sub­si­dies through the fed­eral ex­change. We’re glad to see that this thing will prob­a­bly move faster to­ward some sort of Supreme Court res­o­lu­tion.

MH: What would hap­pen if the Supreme Court struck down sub­si­dies in states us­ing the fed­eral ex­change?

Umb­den­stock: That would mean a whole lot less cov­er­age and a whole lot more con­fu­sion. I think Congress in­tended for peo­ple (in all the states) to get th­ese sub­si­dies.

MH: What do you see as the future of mov­ing to value-based pay­ment and of fee-for-ser­vice draw­ing to a close?

Umb­den­stock: The move­ment to value is here to stay. It’s go­ing to take Medi­care a while to move off fee-for-ser­vice, and that’s a bell­wether. But there’s a whole lot more in Med­i­caid and Medi­care man­aged care. The non­govern­men­tal pay­ers are all mov­ing in this di­rec­tion. We all as­sume feefor-ser­vice will be greatly di­min­ished.

Large na­tional em­ploy­ers can be real in­flu­ences in their re­spec­tive mar­ket­places. And you see states try­ing to limit their ex­po­sure as well. It could be a global bud­get ap­proach with a tar­geted rate of in­crease, as in Mary­land and Mas­sachusetts. In Mary­land, 10 ru­ral in­sti­tu­tions have adopted the value ap­proach of less uti­liza­tion, more com­mu­nity-based ser­vices, and less re­liance on in­pa­tient care be­cause they only get a fixed amount of money. They are out in the com­mu­nity col­lab­o­rat­ing with so­cial ser­vice providers. I see them em­brac­ing it and it’s ter­rific.

The future will be in re­serv­ing acute care for when it’s ab­so­lutely nec­es­sary but try­ing to reach the com­mu­nity through less in­ten­sive, less ex­pen­sive forms of in­ter­ven­tion. But ev­ery­body’s ques­tion is, how do you make it work fi­nan­cially?

MH: Will there be a back­lash against nar­row net­works as in the 1990s?

Umb­den­stock: The jury is out as to how well that works on the ac­cess and cus­tomer sat­is­fac­tion side. We’ve been through one cy­cle of this on the ex­change level, and you’re start­ing to see some tinkering with those net­works. On the provider side, you’re see­ing peo­ple say, how do I be­come one of those pre­ferred providers? So there’s move­ment in the mar­ket. The good news is we see pos­i­tive pa­tient re­sponse and per­for­mance in­di­ca­tors from provider-spon­sored plans. We ac­tu­ally have rat­ing sys­tems and mea­sures this time. We didn’t have those in the 1990s. There’s a level of ac­count­abil­ity and trans­parency that wasn’t there back then, and that gives me hope.

MH: With pop­u­la­tion health, how will the role of physi­cians change?

Umb­den­stock: Physi­cians will prob­a­bly play ei­ther more of a con­sul­ta­tive role within a larger team, or their ser­vices will be re­served for is­sues of clin­i­cal am­bi­gu­ity that no other team mem­ber is as qual­i­fied to ad­dress. They may be see­ing fewer pa­tients who are more ap­pro­pri­ate to their ca­pa­bil­i­ties and spe­cial­ties. That would be more re­ward­ing. Would they have as much con­tact with as many pa­tients? Maybe not. Would they have more time for the truly se­ri­ous con­di­tions when the pa­tient needs that clin­i­cal sup­port and the re­as­sur­ance that they’re get­ting the high­est level of ex­per­tise? There will be dif­fer­ent prac­tice mod­els, and I think much of it is for the good.

MH: Is having net­works com­pete with each other, such as in Pitts­burgh, a long-term pos­i­tive for the health­care sys­tem?

Umb­den­stock: His­tor­i­cally, my mem­ber hos­pi­tals have com­peted based on ar­ray of ser­vices and level of tech­nol­ogy, and now they’re com­pet­ing more on cost,

“What I’d like to see is some ac­knowl­edg­ment that the en­ti­ties in the sys­tem have to be con­nected more closely to get to the type of co­or­di­nated care we all want to see.”

pa­tient sat­is­fac­tion and qual­ity out­comes. In that sense, it’s healthy for us. But we’re start­ing to fig­ure out where com­pe­ti­tion should and shouldn’t oc­cur. Pa­tient qual­ity and safety should not be a com­pet­i­tive is­sue. When we fig­ure out what works, or when we have in­for­ma­tion in one sys­tem that is nec­es­sary to treat a pa­tient who is be­ing treated else­where, we need to be able to share those suc­cesses and move that in­for­ma­tion. Com­pet­ing on price and pa­tient sat­is­fac­tion is fine, have at it. But on qual­ity and safety, if the Amer­i­can Hos­pi­tal As­so­ci­a­tion could find out what works in one in­sti­tu­tion, we want to spread it to all oth­ers be­cause ev­ery in­sti­tu­tion should be the safest place pos­si­ble for pa­tients.

MH: Is there a mixed sig­nal from Wash­ing­ton on con­sol­i­da­tion and an­titrust en­force­ment?

Umb­den­stock: They are not forc­ing peo­ple back to square one, tear­ing things up, deny­ing op­por­tu­ni­ties. But it does keep lots of lawyers, con­sul­tants, ex­ec­u­tives and boards busy all the time. Our mem­bers are mov­ing within that re­al­ity. What I’d like to see is some ac­knowl­edg­ment that the en­ti­ties in the sys­tem have to be con­nected more closely to get to the type of co­or­di­nated care we all want to see. We have to be able to fig­ure out how th­ese en­ti­ties can work to­gether legally with­out wast­ing a lot of time and money look­ing over their shoul­der. I’d like the gov­ern­ment to think about a more ap­pro­pri­ate set­ting go­ing for­ward.

MH: What would you like to see hap­pen on the Medi­care rule re­quir­ing a three-day in­pa­tient stay be­fore pa­tients qual­ify for cov­er­age of re­hab care?

Umb­den­stock: We’d cer­tainly like to see that sort of thresh­old less­ened if not elim­i­nated. But that’s go­ing to de­pend on the type of pay­ment sys­tem, in­cen­tives and ac­count­abil­ity mech­a­nisms in place. The re­al­ity at the mo­ment is that if you try to elim­i­nate the three-day rule, it would in­crease Medi­care spend­ing. How are you go­ing to find sav­ings else­where? If you want to bun­dle post-acute care and give the providers a fixed amount of money to take care of their post- in­pa­tient needs, then fine, we’ll take that. Now, how do we man­age it? Can we move the pa­tient to the most ap­pro­pri­ate level with­out having to worry about th­ese par­tic­u­lar hur­dles?

MH: What’s the out­look for re­form­ing Medi­care physi­cian pay­ment?

Umb­den­stock: I don’t think the po­lit­i­cal cal­cu­lus has changed, which is that fixes need to be paid for. We are cer­tainly mak­ing our view clear that tak­ing the money from one provider en­tity to pay for a fix in an­other area is not real re­form and doesn’t make sense. We think that the physi­cian pay­ment sys­tem should be fixed in and of it­self. But we’re not happy be­ing the tar­get of cuts on a re­peated ba­sis.

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