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By Deborah Donovan
Your health care will change as part of a revolution in the industry going on now, regardless of how the U.S. Supreme Court rules on the 2010 health care reform act, according to Bruce Crowther, president and CEO Northwest Community Hospital in Arlington Heights.
Crowther recently sat down with the Daily Herald to explain what he sees as the future of health care in the United States, asserting that even if the Supreme Court rules the health care law unconstitutional, it probably will be replaced by something else to continue an industrywide reorganization.
At the center of that change is an ongoing push by both private insurers and Medicare to financially reward health care providers for keeping you out of the hospital and away from the surgeon's knife.
"Studies show that of developed countries, America is the most costly (health care system), and we are in the middle of the pack for length of life and all the things you might use to measure health," Crowther said.
The government and insurance companies are funding pilot programs to try to come up with new models that give better outcomes for patients at lower costs. But in the meantime hospitals like Northwest Community, where about half the patients are on Medicare, will be penalized starting in October if their number of patients readmitted within 30 days is above a national norm.
Crowther says he would like to see a system in which a new patient joining a medical group would begin by receiving an intensive physical paid for by the insurer. If the physical reveals any chronic diseases that could lead to a hospitalization, the patient would be assigned a home health nurse or advanced practice nurse to be in weekly contact.
"He or she would make sure you are taking your medicine and complying with the doctor's orders," Crowther said. "This has been done in other parts of the country, and the outcomes are really remarkable for reducing the number of hospitalizations."
The health care law currently before the Supreme Court is intended to reduce the cost to government for Medicare and Medicaid, and to bring health care coverage to an additional 30 to 35 million people.
From Crowther's point of view, the "individual mandate" portion of the law requiring insurance means people would no longer come to the hospital without insurance. The country needs to decide whether everyone should have insurance or whether society and in part insurance companies should continue to subsidize them.
"I can't say health reform is bad, but Congress was much more detailed than they needed to be," he said. "I believe there's some flexibility in Washington. There are financial incentives to keep people healthy, and radical kinds of things could come out of this."
Here are some topics Crowther discussed:
Pilot programs: Pilot programs are a good way to learn what's effective and what's not, and the NCH Medical Group (physicians employed by the hospital) works on one with Blue Cross/Blue Shield. Initially about 200 patients are in the program. The goal is to use coordinated care to avoid hospital admissions for high-risk patients.
"What happens is a Blue Cross patient or company who buys insurance can go anywhere, but if they want a special price, they have to go into this medical group. They receive an intensive assessment and proactive monitoring. It costs more for the front-end assessment, but there's savings on the back end, and the insurance company helps us share the cost of additional advanced practice nurses. It's testing what works and what doesn't on a small scale. Unlike most insurance contracts, we are able to adjust pilot programs if needed. This is a way to get improvement in health and cost."
Lawsuits: "We need tort reform. I know what you have, but if I ever have to prove it in court I need an X-ray. People in Washington are not ready to touch tort reform."
The 'system': "They said the system of health care is broken. There is no system. There is no relationship between the different parts. (Medical providers) send patients to each other all independent of each other. We don't need to work together. Under the new system if we are prepaid and responsible for your health, we will no longer be paid to do volume, we will be paid to keep you healthy."
Reactions to reform: "We're operating in the old world while building the new world. It's a better system. But there's a lot of angst among caregivers about the transition. How they get paid might be at risk. But there's an appreciation that they are finally getting to do what people got into medicine in the first place for — to keep people healthy. We're energized but a little nervous. We are finally taking advantage of the skills that we have for maintaining health."
Ideas: Northwest has a Wellness Center on its campus. Maybe it would give people in its health care system a discount for membership or not charge them at all. Perhaps health coaches would be added to the fitness trainers.
Primary care physician: The primary care physician needs to be aware throughout whatever happens to the patient. He or she is "the most important player still. The Northwest suburbs are relatively affluent and well educated, but only about one-half of the people here have a primary care doctor. We have to function as a team. The requirements for us to communicate and cooperate are much higher."
Numbers: The bill anticipates lower costs by lowering use rates. The national average is 106 admissions per thousand, but in California HMOs like Kaiser hit closer to 75 out of a thousand, and they are trying to get it down to 48. Dartmouth has been studying this issue for 20 years. Certain communities admit a lot of people to hospitals. Others don't. They publish that and get communities to establish what best practices are nationally; they're all surprised how quickly best practices are adopted.
The hospital: Admissions to NCH are down 10 percent. "We are putting in programs to lower our readmission rates to prepare for October and the Medicare payment incentives. The hospital is the most expensive point of contact" compared with outpatient services and nursing homes. "Fifteen years ago our revenue from outpatient facilities was 5 percent, and it was 95 percent inpatient. Today the hospital is less than one-half." There is a strong emphasis on outpatient work for such things as X-rays and even surgery.
The hospital should be investing more in doctors' offices. What will the hospital do if it has extra space? Perhaps create hospice and rehabilitation areas.
The best: Communities like to have all of their services at local hospitals. In less than 1 percent of care the person needs "esoteric surgery," which means that very few of these procedures are done. In those cases "we do need to be able to find that person that's the best." Hospitals renowned for certain treatments might be considered in-network for the rare cases.
"My hope is the new system will continue to allow that."