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The Business Case for Integration: Perspectives from the 5th Annual AHA/Health Forum Conference PDF Print E-mail
Written by John Weeks   

The Business Case for Hospital Integration: Some Perspectives from the 5th Annual AHA/Health Forum Conference

Summary: The attendance at the Health Forum/American Hospital Association's annual conference, Integrative Medicine for Healthcare Organizations, jumped 58% this year, from 160 to 260. These attended a meeting which recognized that mission alone can only move hospital integration of complementary and alternative services so far. What is needed is a business case to support the integration. This year Health Forum partnered with the Samueli Institute, which has establishing the business case as a core goal. Here are some perspectives on money and integration which came forward at the meeting ... including a health system CEO's perspective that we may need a government mandate.
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On April 12-14, 260 professionals involved with hospital-based integration of complementary and alternative services into healthcare organizations met in San Diego for the Health Forum/American Hospital Association's 5th annual Integrative Medicine for Healthcare Organizations. For participants at the meeting, part of the reason for excitement was the turn-out. When it comes to system-change, size matters. Attendance jumped from 160 the year before, a 62% increase. The 100th monkey, if not actually in the room, seemed to be somewhere on the Rancho Bernardo grounds.

Image Talk among integrated care advocates has always speculated on how hospital medicine's twin crises of safety and cost would channel energy toward the promises of integrative health care. Now here, speaking on the topic, were hospital CEOs from small rural systems like Windber Medical Center and Grinnell Regional Medical Center and major metropolitan systems such as Allina Hospitals and Clinics in a more typically liberal Minnesota. All were stumping for integrative care.

On the conference's last day, Martin Merry, MD, provided a keynote speech. Merry is a nationally-recognized hospital consultant who has worked with the leadership of over 1000 healthcare organizations on safety and quality issues. Merry announced in the middle of his talk that, following two days of living with these activist leaders of the integrative care movement, he was making a significant change in his stock slide presentation. Until the meeting, Merry typically presented healthcare change as shifting from a "culture of craft" - focusing on the skills of physicians - to a "culture of safety/excellence." Under the influence of his experience at the conference, Merry re-characterized the new era. He decided that the emerging "culture of safety-excellence" would be better denominated as a "culture of integrative practice."

This column takes a look at aspects of the business model which may give some buoyancy and oomph to that emerging culture.

1.   Wayne Jonas, MD and the Samueli Institute 's Health Services/Business Agenda

ImageWayne Jonas, MD, the former director of the NIH Office of Alternative Medicine, has always distinguished himself among complementary and integrative medicine researchers by his clarity that if we want to change health care, researchers need to develop data on the business case. Researchers need to wade into the world of dollars. AHA/Health Forum meeting planner Sita Ananth, MHA, had the smarts to bring Jonas and his team at Samueli Institute, led by vice president for optimal healing environments, Barb Findlay, RN, into the meeting as content partners.

Jonas described some of the Samueli Institute strategy in his presentation. The core plan is to
develop collaborative relationships with selected healthcare systems, including the 3 systems noted above. Working with these, Samueli will develop and pilot a health services research agenda that "measures clinical, professional and economic outcomes" of optimal healing environment components. Jonas asserts that "we must start measuring what we value." This means selecting the "right indicators of success." Samueli Institute and its health system partners have identified some key patient and provider outcomes relative to healing and begun to link them with outcomes already being collecetd by hospitals.

 "Right indicators of success"

 "Conventional health services
data already being collected"

 Quality of life    Quality of care
 Mind-body practices    Patient safety
 Communication    Patient satisfaction
 Empathy    Practitioner satisfaction
 Social support    Practitioner retention
 Well-being,   Patient pain
Purpose   Direct costs

Jonas makes the case that "the information and outcomes are already there." Then he adds: "The challenges -and these are significant - are to correlate them." For instance, one focus is on "practitioner retention." To what extent might a nurse's enjoyment of having some integrative services available (mind-body, massage, etc.), both to receive and participate potentially in delivering, strengthen the nurse's institutional loyalty and influence the nurse's desire to stay. If integrative services or an optimal healing environment can do this, the hospital avoids the very expensive costs associated with nurse replacement ($75,000 per incidence according to the Medical Group Management Association). The cost benefit analysis takes a more global accounting.

Samueli has brought a seasoned health services researcher Mike Finch, PhD, in to help take a lead in crafting the projects.

2.   Will Freeing Beds Through More Rapid Healing Times Be the Big Bonanza for Integration?

Health Forum conference advisory committee member Milt Hammerly, MD
shared with me an insight on where the biggest dollar benefits to a hospital may come from appropriate application of integrated care. The benefits Hammerly forecasts would come from the package of services which Samueli Institute bundles as creating "optimal healing environments." Hammerly, also an Integrator advisor, is vice president for operations and integrative medicine for the 19-state Catholic Health Initiatives system.

Health Forum advisor Milt Hammerly, MD
Hammerly acknowledges that if a hospital is paid for every day that a patient is hospitalized, hospitals have little economic incentive to more a patient through the hospital quickly. This
dis-incentive structure reverses with Medicare's prospective payment system. Under prospective payment, hospital fees are tied to specific length of stay for given conditions, procedures or surgeries - or diagnostic-related groups. Hospitals have functionaries who are skilled in the obscure arts of coding and billing who seek to understand and manipulate these things. Suffice it to say that the actual bottom line is that if patients end up in hospital beds after the payment runs out, the hospital has no money coming in.

Hammerly references a presentation he had recently heard at another conference. The presentation was called "Building the Business Case for Quality" and was presented by
William Ward, MBA, from the Johns Hopkins Bloomberg School of Public Health. Ward shows how strategies for implementing patient safety initiatives promoted by Donald Berwick, MD and the Institute for Health Improvement  lowered average length of stay by 22%. Lower length of stay means beds are more quickly available for new patients. Hospitals don't have to engage capital costs of construction to have more beds available. Ward calculated that additional revenue from increased capacity was nearly calculated at $9.8-million for the term of the study.

States Hammerly: "If creation of an optimal healing environment and offering of integrative health services can demonstrate a similar effect on length of stay, that would be a very compelling business argument." Hammerly noted that he intends to explore some of this, retrospectively, in some hospitals in the CHI system, adding: "It would be much more persuasive to show this prospectively but at least we can start by looking at the information we may already have."

Image3.   Bravewell Clinical Network: Most Financially Successful Services

Anyone looking for boilerplate on how to make money in a hospital based integrative clinic will have had their dream of a cookie-cutter broken by the presentation on the 8 hospital-based integrative clinics linked together as the Bravewell Clinical Network (BCN). A presentation on BCN, formed by the Bravewell Collaborative, included a brief note on the "most financially successful services" at each of the clinics. The findings were presented as follows:

 "Most Financially
Successful Services"

Scripps Center
for Integrative Medicine

 early detection center
UCSF Osher Center
for Integrative Medicine

 acupuncture, psychiatry
 Advocate Medical Group Center
for Complementary Medicine

 University of Maryland
Center for Integrative Medicine

 Continuum Center
for Health and Healing

 integrative pediatrics
 Duke Integrative Medicine
 Alliance Institute
for Integrative Medicine

 "ACE" treatment
(a combination of Acupuncture,
Chiropractic and Energy healing)
Jefferson Myrna Brind Center
for Integrative Medicine

 Physician consultations

Hard to find a pattern here. Imagine the newbie to integrative medicine, attending the meeting to fact-find ideas for a system which is thinking of building an integrative program at a hospital. Alas, no simple answers.

4.   If All Else Fails, Promote a State Mandate for Preventive Services

Allina Hospitals and Clinics is in an enviable position, compared to many systems, as far as integrative services are concerned. The system's Abbott Northwestern Hospital is the home favorite of the most influential donors to integrative medicine, Penny George and Bill George of the George Family Foundation.

But even the largess of the Georges has not made integrating care a done deal. Allina's president and CEO Dick Pettingill expressed concern about the challenges hospitals and health systems have in dedicating the resources to do the right thing in hospital care. Then he expressed the depth of his frustration, in action terms:

"I am thinking about going to the legislature for legislation that would require us to give 5% of net operating revenues to (health oriented) initiatives."
Comments:  The Samueli Institute's dedication to developing the business case for integration is both wonderful, and long overdue. Attendees at the Health Forum meeting could not but be impressed by the quality and dedication of the CEOs of Samueli Institute's health system partners from Allina, Windber and Grinnell whose views were on display.

Yet Jonas, Findlay, Finch and their partners face significant challenges. This is, after all, a disease care system with economic incentives perversely aligned with the worsening of disease. The team appears to be asking the right questions. Hammerly's suggestions should be added to the list of outcomes, if they are not already there. Throw in the revenues from freed-up hospital beds. Throw in the foregone construction costs. Whole person care looks best with a correspondingly global net for outcomes.

Yet, as noted, this initiative is long overdue. And clearly at least Allina's Pettingill appears to be concluding that the "business case" will best be made as a public health case. The private, for profit drivers in the US medical system may simply be too opposed to health creation for any business model to be born from within. Dollars to support doing the right thing may need to be mandated by government. Big brother made me do it. Yes, I'm doing the right thing. Big brother made me do it.

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