September 13, 2019

5 conversations that changed our minds about health care

Daily Briefing

    Advisory Board researchers have dozens of conversations a week with experts across health care—each one leading to at least some shift in the way they think about the industry. But occasionally they have a conversation that fundamentally changes the way they view things.

    Infographic: 4 key changes to make to your existing communication strategy

    Here are five of the conversations that have been most impactful—and the lessons they taught. 

    1. Why patient choice in discharge planning isn't as simple as it seems

    Monica Westhead , Practice Manager, Post-Acute Care Collaborative

    I had been working as a researcher in the post-acute space for two years before I saw the discharge planning process firsthand. What I saw changed my perspective on patient choice—and gave me a new passion to improve the process.

    A family member was hospitalized following a serious cardiac event, and needed to go to a skilled nursing facility to continue to recover before going home. The day before her planned discharge, a Medicare coordinator came into her room to provide her with her choices for post-acute care—a three page, alphabetized list of all of the SNFs in the area. No guidance, no advice. Just "you have your choice." Being very sick, she wasn't in any condition to make a choice. Her spouse had nothing to go on except names and addresses, and was stressed by the burden of deciding for her without useful information—and worrying that he would make the wrong choice. 

    I was floored.  She was at a high-quality health system. I knew from working with them in the past that they had a post-acute network in place, but there was nothing on the paper that indicated who those partners were, or how they chose them. I found myself sitting in the hospital room, pulling up Nursing Home Compare and the Post-Acute Pathways Explorer, trying to figure out which of the options had the best readmission rates in the few minutes we had until the discharge planner returned. 

    Ultimately, this kind of "choice" isn't much of a choice at all—it's more like roulette. Cross your fingers and hope you've picked a good option. As an industry, we're asking people to make these critical decisions blind, at one of the most vulnerable times in their lives.

    So many health systems have created preferred post-acute networks based exactly on the kinds of things that patients would want to know when making their choices. And yet they are often afraid to share that information with patients, to avoid influencing their choice. The outcome: patients who don't know where to go, and may end up at lower-quality providers—bad for the health system, and certainly bad for the patient.

    Patient choice is critical, and patients deserve to have their voices heard and their preferences honored. But I learned through this experience that supporting patients in making an educated choice is even more important. Health systems create preferred networks for a reason: to improve outcomes by working with higher-quality providers in a market. But all that work is for naught if the patients don’t go there, because they don't know about it. Actually using the networks—teaching discharge planners what's acceptable within patient choice regulations (hint: more than you think!), and providing patients with that information—creates a better experience for patients and families.

    For more about how to direct patients to high-performing post-acute partners, view our Guide to Promoting In-Network Utilization.

    2. Why I question decisions just for 'clinical benefit'

    Brandi Greenberg, Managing Director, Life Sciences

    The conversations I had with a relative who had been diagnosed with breast cancer were some of the most impactful of my life. As I helped her navigate the cancer care system, I came to realize the difficulties patients face in advocating for their own needs and priorities when making treatment decisions. My relative, in her 70s, had been diagnosed with an aggressive, but early-stage cancer. She'd already survived an earlier, unrelated bout with cancer 20 years ago, for which she'd had surgery, radiation, and chemotherapy (and had experienced the side effects of each modality). 

    In counseling her, I saw firsthand just how fragmented cancer care remains for many people in the US. The PCP, medical oncologist, and surgeon weren't coordinated—which meant that my relative got mixed messages and incomplete information about her tumor type and treatment options. Even after we got her a second opinion with a health system offering a more team-based approach, my relative had trouble getting clear answers to her questions about the various treatment options. And when she decided on a less aggressive treatment plan than the doctors recommended, I was frustrated by the pushback she heard. Her reasons were very sound and based on both lived experience and credible research, yet her priorities didn't seem to carry nearly as much weight with her clinicians as what the protocols dictated. As a result, in my own Advisory Board research, I've become more interested in ways to elevate the patient voice—not only in choosing or adhering to treatments, but in guiding our thinking about what counts as a "clinical benefit" or medical value. 

    3. What a party of medical students taught me about physician pay

    Thomas Seay

    Jackie Kimmell, Senior Analyst

    Fresh from re-loading my plate with chips at a medical student friend's recent party, I stumbled upon an intriguing conversation. "Urology makes how much?" one person was asking as he sipped a beer. "Oh a bit over $400 thousand," a girl responded matter-of-factly, "It's not as good as dermatology, but who has the board [examination] scores to get into that?"

    Over the next ten minutes, the second-year medical students discussed almost every specialty in turn, with one girl pulling up her phone to call out the average yearly earnings for each one. "I mean radiology makes so much," one whined, "but I just can't see myself sitting in a dark room all day staring at people's bones."

    I listened to the whole conversation—mesmerized by the whole affair. Of course, I knew that salaries were a major factor in the specialty choice that medical students made. As many of our Daily Briefing articles have shown, the choice can lead to a difference in $350,000 per year in earnings.

    But what struck me in that conversation was just how much salaries mattered to the students assembled, many of whom were no older than 24. Most of them had been in school their entire lives, spending long nights in the library while their non-pre-med peers had been out partying, and going back to school while their friends had the freedom of their first jobs after graduation.

    Therefore, for many, the prospect of making hundreds of thousands of dollars gleamed like the Land of Oz at the end of a long journey, and filled them with a childlike glee. Viewed in this lens, salaries took on a mystical level of importance—far above the other considerations, like work-life balance, work environment, or subject matter that play into a residency choice. The same friends who had triumphantly returned from a night babysitting in college saying they were definitely going into pediatrics now had different considerations.

    Now, of course, its worth mentioning that many were also worried about paying off the hundreds of thousands of dollars of medical debt that would hit them when they donned their white coat. Those worried about the accruing interest of this debt wanted to make as much as they could pay it off as soon as possible, even taking a lower-paying specialty which would require less training.

    But for those who had family support or faith that they could pay off their loans in the long-run, salary was paramount in their decisions. I think that this is only natural—doctors are humans, of course. But I also think that when we think about the possible physician shortage, the shortages of certain specialties, and the epidemic of physician burnout, it's worth thinking about the students sitting in that room. For many of them, high pay was a prize after years of exhaustion—and they were going to do whatever it took to make that prize as large as possible.

    4. Why my cat made me see health care spending in a new light

    Thomas Seay

    Thomas Seay, Executive Editor, Daily Briefing

    The conversation that changed my mind about health care was brief, tear-filled, with a veterinarian, and involved … a cat. But bear with me, because it truly shifted my thinking about health care spending.

    In the summer of 2014, I'd just started a terrific job that had boosted me into the best financial position of my life. Naturally, because fate can be cruel sometimes, that was also the summer when my beloved cat Gadget suffered acute kidney failure.

    Some important context: Gadget was my once-in-a-lifetime cat. She was a seven-pound ball of fluff who liked to wait atop my refrigerator each afternoon and leap onto my shoulders as I entered my apartment door. Then, she'd loop around my neck and perch there for as long as I'd let her. (Also, she pooped on the floor a lot. Nobody's perfect.)

    So when the veterinarian told me that hospitalizing Gadget, even for a few days and with no promise of a good outcome, would cost thousands of dollars, my choice was easy. Of course I'd pay the money—especially because, thanks to my new job, I could more readily afford the bill.

    My only focus during that short, painful conversation was on Gadget. But years later, after the emotional fog cleared, I came to see how that brief interaction had revealed something important about health care.

    My realization wasn't merely that health care spending—whether for humans or animals—is emotionally charged. Rather, what struck me was how, from my newly comfortable financial position, I felt joyful about bearing this cost. Like, what else would I spend those extra dollars on? A bigger apartment? A nicer television? None of those held nearly the appeal of giving Gadget a shot at a longer life.

    To zoom out radically from the personal to the systemic: If you'd asked me previously why U.S. health expenditures were increasing so sharply, I would have pointed to declining competition, rising costs of drugs, overuse of low-value services, or some other perceived dysfunction of the system—and I still think many of those explanations have merit. But now, I also find myself thinking, "As our society gets richer, what else would we spend money on rather than longer, healthier lives for ourselves and our loved ones?"

    From this perspective, rising health care spending is not always and everywhere a problem. Rather, it is—at least sometimes—the rational way an increasingly wealthy society chooses to spend its money.

    I'm hardly the first person to connect health care spending for humans and for pets. If you’re interested in digging deeper, you can find a more rigorous exploration in a study with the provocative title, "Is American Pet Health Care (Also) Uniquely Inefficient?"

    (A coda: In the end, we had to put Gadget to sleep. Even so, the money I spent on her final days remains one of the best purchases of my life. It gave me the peace of mind that I did everything possible to save her, and that, literally, is priceless.)

    5. Why it's worth being patient with the hype around the word 'innovation'

    Amanda Berra, Senior Research Partner, Health Care Advisory Board

    I started this year's Health Care Advisory Board research on innovation strategy as a skeptic of the very word 'innovation'. I'm a skeptic because it feels overused and vague— and often seems like a prelude to a lot of name-dropping of people and companies in Silicon Valley. Plus, I think there's a danger of hospital and system executives spending a lot of time focusing on what disruptive innovators themselves are doing, without learning the core lesson of their success: to put a laser-focus not on external competition or threats, but instead on better serving their customers. It's a lesson we should all put front and center.

    However, I had a turnaround moment with the word 'innovation' right out of the gate. I was talking informally with executives of a health system about something else: the fact that many of the best improvement opportunities in health care are not strictly about addressing cost, clinical quality, patient experience, access, or provider burnout, but actually end up addressing all those objectives at once. Conversely, most systems have a million individual improvement initiatives going on at any one point—each of which targets just one of those objectives at a time. Frontline staff find themselves tasked with implementing all of these initiatives, but feel the weight of these more systemic problems. And they have no clear avenue to help fix them or to suggest how to do so. The strategy executive turned to his colleagues and asked, "Didn't we once have a hotline for submitting improvement ideas?" The CFO answered, "Well, at one point we had a dedicated email for sharing cost savings ideas… but no one ever used it."

    AHA. Here was at least one compelling case for using the word 'innovation'— and a reason why it would be a serious waste to throw the term out with the buzzword bathwater. 

    Yes, it can seem like a catchall. But it's a catchall that happens to inspire people (certainly more than "send us your cost savings ideas"). We are living in a world where cost, quality, patient experience, access, and provider burnout issues are all intertwined. Care quality can be the spark, and cost savings may ride along as part of the ROI—or vice versa. Therefore we need a concept—and also a competency—that we can seize, elevate, and use as momentum to solve many related problems at once. 'Innovation' is the key to cross-cutting initiatives.   

    Now that my team is further down the road of research on this topic, it's much more clear to us what the potential of 'innovation' is for health systems (and how much work is needed to capture that potential). But I'm officially a convert. For others out there who are still struggling with the word innovation and its "weird veneer" (as one of my research colleagues poetically calls it), I think what we all need to do is get past it, separate the fluff from the substance, and focus on what it can do for us.  

    To learn more about what we found are the right (and wrong) ways to innovate, make sure you register for our upcoming Health Care Advisory Board national meeting.

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