Doing Good Differently

Even though I am now on the beach, I think about things as if I still am CEO of a health system.  It is easy to do that when you don’t have all the day-to-day responsibilities of an actual CEO.

Where do you take an organization which has developed a nice array of both inpatient and outpatient services and has been able to integrate a health plan into the mix?

There are many directions a healthcare  organization can go to fill unmet needs.  At this point in my life I see many opportunities to offer services to aging baby boomers and members of even older generations.  I have seen the need in my own family with older relatives.

Here is a brief look at some ideas worthy of exploration as health systems look to expand their services for the fast growing older sector of the population:

Medical Fitness Centers:  These are fitness centers open to all ages and fitness levels with a twist. There is a more medical orientation with highly trained staff helping to develop fitness regimes which take into account the special needs of members with chronic conditions.

NorthBay Healthcare opened a 55,000 square foot medical fitness center in 2016.  It’s where I spend the first part of every beach day.  Whether you are fit already, want to get fit or need to maintain your fitness level post-rehabilitation from an illness, medical fitness centers are a natural fit for those who look to a particular health care system for care. Medical fitness centers also help to build your brand and provide “stickiness” with existing patients.

Glenner Town Square:  Some years ago I was in Amsterdam and heard about a memory care residential facility which recreated a small Dutch town in the 1950s.  Using what was called “reminiscence therapy”, this facility had a positive effect on dementia patients who live there. A stroll down memory lane makes a difference.

This concept was adapted in the United States by the George G. Glenner Alzheimer’s Family Centers (www.glenner.org). The primary difference is that these centers provide day care rather than residential care and the “Glenner Town Squares” are 9000 square foot replicas of 1960s America contained within an existing building.

Continuing Care Communities:  This is for those organizations which think big and have the resources to back up their big thinking!  Continuing care communities (CCC) are not a new concept.  Demographics are making the need for such communities grow.  I have a friend who is in her early 80s and has just recently moved from her large home into a CCC.

CCCs come in a variety of configurations and can be for-profit or non-profit in organizational structure.  CCCs which offer independent living, assisted living and memory care to my mind are the most comprehensive and attractive.  I tend to think of them as Club Meds for the older set.

You don’t see very often local healthcare systems offering CCCs as part of their care continuum.  That’s a shame because they are a natural fit.

There are other possibilities as well along the continuum of care. What you do depends upon the definition of healthcare which your organization has adopted. If your mission is some variation of ” fix the sick”(and there is nothing wrong with that), then staying on the acute care part of the continuum is where your organization may be best suited.

If your organization wants to help people be healthy, then there is a broader palette of healthcare possibilities available. With longer lifespans, I think most healthcare organizations need to expand their care continuum to take advantage of other possibilities.

It is very sexy currently in health care to look for the “disrupters” in healthcare–often a nerd who thinks using an iPad in patient care is the height of innovation.  Down at the actual service level, there are great unmet needs which could be met and in the process bind people to a healthcare system in a positive and long-lasting way.

I am a baby boomer and there are still millions of us yet to hit the beach.  We are all going to need  more options on the beach.  If those of us who are in health care are truly committed to the idea of care continuity, there exists great opportunity for health care organizations to do well by doing good in meeting these needs.

The Bobble Head Quest

Last Saturday was the “Big Game” at Memorial Stadium in Berkeley.  Cal’s annual game against Stanford had been delayed for two weeks due to poor air quality resulting from the devastating fire in Butte County to the north.

I am a long time holder of six season tickets for which I pay through the nose.  In addition to the outrageous price for each ticket, I have to make a “donation” annually so I can maintain my specific seat locations.  Each game represents an expenditure of about nine hundred dollars not counting the price of luke warm hot dogs.  With seven home games this year I spent over five thousand dollars which was more than I spent in tuition for my undergraduate degree at Cal.

This year’s Big Game had an additional attraction.  Cal was giving away a bobble head to commemorate “The Play” of 1982 when Cal won the Big Game in a lateral crazy last play kick off return.  The first ten thousand attendees would receive a bobble head and since I was present in 1982 I especially wanted one.  That is ridiculous at my age but I still reserve the right to be occasionally ridiculous.

My oldest son and I showed up at the stadium an hour early so we could be sure to claim our bobble heads.  We always enter through Gate 3 which has a special entrance for season ticket holders.  It is a way to avoid the crowds although most games are not that well attended.  Gate 3 is also the entrance for high school students being recruited for various Cal sports including football.

We had our tickets scanned and seeing boxes full of bobble heads asked for two.  We were told those bobble heads were reserved for recruits only.  You would think for five thousand dollars it would be easy to get the bobble heads.  No dice.  I was told that I might be able to get bobble heads at “Customer Service” on the plaza level.

No stadium staff members on the plaza level knew where “Customer Service” was. Getting increasingly frustrated in my quest for a bobble head, I headed to the main entrance at the North end of the stadium.  Nirvana!  There were thousand of bobble heads waiting for a home.

I went up to the ticket taker and another staff member who appeared to be a supervisor, explained what had happened at Gate 3 and asked for a bobble head for me and my son.

No dice again!  It was explained to me that the policy was that you could not be given a bobble head once your ticket had been scanned and you had crossed the ticket line.  My protests were met with no sympathy.  My ridiculous quest for a bobble head appeared to be at an end.

Then I got an idea.  I had three unused tickets for the game in my pocket.  Could I go two feet outside the stadium and have my unused tickets scanned as if I was entering for the first time?  Would that get me a bobble head?  There was a brief conference between the ticket taker and the supervisor and they gave approval for this brilliant move on my part.  I had my bobble heads and it only took me thirty minutes of effort.  That’s customer service!

Actually it was poor customer service. Cal’s football stadium is directly across the street from the Haas School of Business where I earned my bachelor’s degree.  Maybe there is an expert in customer service over there who should be consulted.

This would be funny if such unthinking responses only occurred at college sporting events.  Unfortunately, it also happens more often in healthcare than it should.

Even though I am now on the beach, I frequently get approached by people asking my opinion about an experience they had in accessing healthcare.  These inquiries are not about  “quality” as defined by the experts.  The typical patient is not concerned about hospital infection rates. As they should, they don’t expect to get a hospital acquired infection.

What they expect is responsive and caring service.  Here is a recent example of the opposite of that.

A man was sitting in a crowded medical clinic waiting room holding in his lap his child who looked between one and two years old.  Suddenly the child vomited on himself and the chair his father was occupying.  The registration clerks apparently did not notice (a charitable interpretation) or chose to ignore the situation.  Instead, two women also waiting to be seen went into action.

This may not be politically correct to say but I bet both women were mothers.  One went to a nearby restroom and emerged with wet paper towels.  The other went to her car and bought back baby wipes and a clean receiving blanket.  Together, they helped the father clean his toddler as well as the chair.  There was no staff assistance.

I have been mulling over this incident and my bobble head quest as I have been making my pre-Christmas shopping rounds.  Some businesses stand out in terms of the great quality of their service.

Amazon delivers (in more ways than one) a great on-line experience.  Chick-fil-A seems to have mastered the care and feeding of harried fast food customers.  Even often maligned Comcast has provided me great service recently.   Some organizations just  seem to get it.

For healthcare providers, the subject of quality is an ever continuing debate.  There is no shortage of measures promulgated by public and private organizations.  There is no consistency of measures.  It is very possible to be highly rated for quality  by one organization and have a low rating for the same area of healthcare by another organization.  I have seen that first hand.

None of that matters if you fail the patient at the entry point of care.  Most healthcare organizations I am aware of work hard at customer service but still fall short.  Why can’t healthcare providers deliver consistently good patient experiences at all points of contact.? Those that do will be the winners in our changing healthcare system.

By the way, to make my Big Game experience complete, Cal lost to Stanford for the ninth straight year.

A Big Boo-Boo

I have time on the beach to read the Wall Street Journal much more throughly than I did when I was not on the beach.  Given the recent volatility in the market, reading the Journal is more of a thrill ride than I like. Nevertheless, I have  been following in the Journal a recent development involving “disruption” in health care with interest

For the past year CVS and Aetna have been in the process of merging.  They recently received the approval of the Justice Department to proceed.  We will be disrupted–or will we?

In a late breaking development also in the Journal, Walgreen’s has just announced that it and Humana are exploring buying stakes in each other.

Why are drug store companies and health insurance companies looking to merge? Are these mergers an unholy alliance of dogs and cats?  Who is the disruptor and who is the disruptee?

CVS and Walgreen’s are being disrupted by trends in the retail market.  I seldom venture into a CVS store which I find typically looks like a bomb exploded inside.  Shelves are in disorder and help is hard to find.  When I do go inside, the stores look more like a grocery store than a drug store.  That is true of Walgreen’s as well.  They have an identity crisis.

I am a good example of why they are in trouble with their core retail business.  I get my electric toothbrush replacement through quip.com and my shaving supplies through harrys.com. These are subscription services providing me with high quality products at a  lower cost.  I get my vitamins and other supplements from Amazon. When I need to get a prescription filled and over-the-counter medications I do it while shopping at my local supermarket.  Who needs a drug store?

These trends have driven both CVS and Walgreen’s to go into the pharmacy benefit management business.  They have done so with some success.  However, it now appears that Amazon is looking hungrily at that business as well.  Where Amazon goes other businesses die.

CVS has also tried with limited success to provide health care directly through clinics in some of their stores.  I visited one such clinic in Washington D.C. and was not impressed.  It was located next to the pharmacy and I had to pass an impressive number of shelves filled with candy.  It was something less than a true urgent care clinic.  Staffed with nurse practitioners and physicians assistants with a do it yourself registration process using tablets (how cool is that) it offered a limited menu of services.  It was what I call a “boo-boo clinic”.  If you have a boo-boo go to CVS and be cool.  Anything  more than a boo-boo go to a real urgent care center or a hospital emergency service.

Similarly, Walgreen’s has some stores offering limited boo-boo clinics.  Some of the locations involve ventures with local health systems.

Walgreen’s is most famous for the venture it had in Arizona with the now discredited lab test business called Theranos. Theranos claimed it had a way to do lab tests which would disrupt the business.  It was a fraud and its founder, a young Stanford drop-out, goes on trial next year in federal court.  It was cool while it lasted but thousands of people were potentially victimized by inaccurate test results.

Now both CVS and Walgreen’s are going to get in the insurance business with health insurance companies which have had difficulty in gaining market share against the competition. Neither Aetna nor Humana have set the world on fire.   CVS and Walgreen’s claim the health plans’ synergy with their other businesses will make them more viable players in health care.

We have seen this story before.  In the 70s Sears owned Allstate Insurance and Dean Witter, a stock brokerage firm.  A section of most Sears stores had offices selling Allstate insurance policies and stocks through Dean Witter.  You could buy underwear, home and auto insurance and a mutual fund in the same place. That was considered cool then.

Today Sear has filed for bankruptcy, Dean Witter has disappeared and only Allstate which was spun off as an independent entity remains a successful business.

Are CVS and Walgreen’s on the right path?  Is there synergy in what they hope to accomplish with Aetna and Humana?    I don’t think so.

Retail drug stores and health plans are not health care.  They are, at best, small players in the real endeavor of health care.  Businesses in survival mode are not a good example of synergy.

The much more disruptive process which is occurring in multiple locations nationally is when hospitals, physicians and insurance companies either have joint ownership or operating agreements which require a sharing of risks of all kinds.  That is real synergy.

When you combine losers you don’t get much. What you get is a business without clarity of purpose.  You just get a bigger loser and a bigger boo-boo.

Swimming With The Sharks

When you are on the beach–my metaphor for retirement–you want to keep your worries to a minimum.  If I wanted to worry I would not have retired from health care.

From the beach you can see sharks circling but you don’t know whether they are man eaters or vegans.  That is worrisome.

I thought that I was through with Medicare for the time being after writing and posting “Medicare For No One” last week.  It was my intent to comment on another subject this week.

Then I saw what might be a shark in the form of a mass mailing from NorthBay Healthcare last Tuesday. They announced that they were going to offer effective January 1 a Medicare Advantage HMO product through the AARP/United Healthcare program.

Was this a shark attack? Should I be worried now that I had a choice regarding Medicare?

Until receiving the announcement I was going for the third year to cover myself and my wife with a finely crafted traditional Medicare coverage from the Feds (Parts A and B), Silver Scripts (Part D Prescription Drugs) and Mutual of Omaha (Medicare Supplement).  It takes a spreadsheet to keep everything in order.

Now I have another choice.  Currently the only insurance company offering a Medicare Advantage plan in my county of residence is the “Big K” ( whom I called the “Elephant” in the blog I wrote for NorthBay).  Since Medicare Advantage HMO programs eliminate the need for a Medicare supplement plan as well as sometimes offering additional coverages, the monthly premiums are significantly lower than traditional Medicare.

With Medicare Advantage plans you give up the freedom to go for care wherever you wish and must agree to have your care “managed” by sharks.  That is probably unfair–I was familiar during my career with health plans who were benign sharks.  Still, a shark is a shark and you need to worry about them.

The result is that my beach time is being spent going over another set of charts trying to decide whether I want to swim with a Medicare Advantage shark.  Once you commit to a Medicare Advantage plan and then decide in the future it is not for you, it may not be possible to get a guaranteed issued Medicare supplement plan when you switch back to traditional Medicare unless certain specific conditions are met.  At this writing I still have not made up my mind about switching.

The Big K as the only health insurance company offering a Medicare Advantage plan in the county is attracting members from other providers because of the cheaper rates.  I know from my own experience there were many NorthBay patients who prefered to stay with NorthBay but absent an alternative to the Big K Medicare Advantage plan decided it was in their best financial interest to switch.  Now NorthBay can seek to attract those patients back. Continue reading “Swimming With The Sharks”

Medicare for No One

You get a different perspective on things when you are on the beach  rather than toiling in an office.  That especially applies to political posturing of which lately there has been no shortage.

Among the slogans bandied about by some candidates in the just concluded election was “Medicare For All”. As a political slogan it had a certain appeal.  It’s a code word for single payor health insurance which is to say the feds or the state.

Already our newly elected governor here in California is backing away from his promise of such a system in California.  Like me on the beach he suddenly has a new perspective on the issue of financing healthcare.

My first reaction to the slogan was the result of my former career–how could healthcare professionals and organizations make it financially if all reimbursement was based on the Medicare model?  Medicare pays what it want to pay when it wants to pay without regard to the cost of providing the care.  The feds also have a vast bureaucracy devoted to making billing and receiving payment for services rendered as difficult as possible.

My second reaction was to remember that I am no longer involved in the provision of health care but am now as a retiree more likely to be a recipient of care.

What could be wrong with Medicare for all?  A lot as I have learned as a fairly recent Medicare beneficiary.  Those who casually advocate for Medicare for all do not seem to realize that it comes with a series of costs to recipients that can adversely affect a . monthly budget.  Medicare is not free care–far from it.

Medicare Part A which covers hospital inpatient services has deductibles which must be paid.  If you are fortunate enough to never have to be hospitalized this is not a problem.  There is no additional monthly premium for Part A. Whoopee!

Medicare Part B covers physician and other services.  This is an “optional” coverage but unless you are into do it yourself surgery you probably should opt into Part B.  Taking Part B requires the payment of a monthly premium which , depending on income level, can range from $135 to $460.  Those are not insignificant amounts, particularly for low income folks in retirement.

Medicare Part D is the Medicare Prescription Program which is designed to help cover the cost of drugs.  It comes with its own set of monthly premiums.  It also uses an income means test to set a monthly premium.  As an estimate I will use $20 a month.

Next comes optional so-called Medigap insurance which helps to cover costs not paid by Medicare.  If you get very sick Medigap insurance is a financial lifesaver.  The cost for this insurance depends upon the coverage and the insurance company selling the product.  The feds provide guidelines for this insurance.  $150 a month per person is a good estimate.

So at a minimum a low income retired couple is looking at monthly Medicare related premiums of $460 and it can go to $1370 or higher for retired couples with the highest income.

For those of us on the beach who can afford it Medicare works but like a lot of us it is creaky.  It is a jerry built design not suited as a model for effective healthcare financing.

“Medicare for All” does not address the real issue of affordability.  It would require the dismantling of the existing health insurance industry which, as dysfunctional as it can be, is still preferable to the monstrous, expensive  and voracious Medicare bureaucracy.  I won’t even go into the massive tax increases for both employees and employers which would be necessary.

Medicare for all?  I am for Medicare for no one other than retirees who paid for it with a career’s worth of taxes.   For all other citizens the country needs  a fundamental rethinking about how health care is financed and also incentives for individuals to adopt healthy lifestyles.

That’s not sexy.  That’s not easy. That’s why our elected representatives never get it done.  Slogans are much easier.  Ask California’s new governor if that is true.

A Revival…..

I retired in March 2017 after 35 years as NorthBay Healthcare’s CEO.   NorthBay is a relatively small integrated healthcare system in Fairfield, California with two hospitals, a 125 member medical group and half ownership of a HMO.

From 2010 until I retired  I authored a blog called somewhat immodestly “The Healthcare Insider” on NorthBay’s website at http://www.northbay.org totaling over 600 entries, some of which were good.

That blog averaged  500-1000 hits each time a new entry appeared.  Even though no new entries have been posted I am told it is still the most popular of the blogs on NorthBay’s site.  That sounds more impressive than perhaps it should since at least one college still includes it in a course reading list.  Pity the poor students.

What I did in the Healthcare Insider is what I proposed to do in the Over The Hill Healthcare Outsider—bring a sometimes different perspective to issues surrounding healthcare delivery once or twice a week.  I can be a contrary person sometimes.

There is a great herd mentality in healthcare. I don’t like being part of a herd if it is headed in the wrong direction.  The healthcare herd tends to lurch  from one new thing to another without critical thought.  For instant, we have been told for many moons now that managed care is the way to go for cost effective care.  Maybe but at least so far the cost curve here in California is often not affected.   The herd may just be wrong.

What this blog will not be is as polished as the one I did for NorthBay Healthcare.  As NorthBay’s CEO I had the services of a great editor who untangled my dangling participles, smoothed my syntax and generally made me look like a better writer than I am.  He also was a Red Sox fan and I understand he has been insufferable lately.

So as an over the hill retired healthcare system CEO I am going to offer my musings about healthcare developments as I contemplate the beach and other joys of retirement.

I do hope that college finds this blog.