"The fault, dear Brutus, is not in our stars, but in ourselves . . ." --William Shakespeare, "Julius Caesar"
--William Shakespeare, "Julius Caesar"
Hospital leaders are certainly at no loss for words regarding the challenges of dealing with our current brand of managed care. Articles such as this one often focus on the problems of authorizations, certifications, denials, payment slowdowns, retrospective reviews and requests for more information. These problems are well-known and well-documented.
But logistic and process problems aside, I strongly believe there is an equally significant issue and opportunity within our hospitals. I contend that we as healthcare professionals often lack a clear understanding of our own internal operations, such that we cannot truly manage the care we provide--or sufficiently influence managed care companies as to the reason why we should be paid for that care. So perhaps Shakespeare's supposition 400 years ago more than applies to our hospital healthcare systems today--that often the fault lies within ourselves.
To determine a possible cause for this lack of understanding, one needs only to lift the sheets on the fragmented nature of our hospital operations. Today, there are just too many different departments involved in creating and operating under negotiated contracts.
These departments, created in response to the ever-changing demands of managed care, have been reactive rather than proactive in the way they've been structured and in the way they conduct their business within the hospital infrastructure.
Because of this, it is rare to see these functionally disparate departments collaborate during day-to-day hospital operations. The handoffs created by this fragmentation and the isolationist model become sources of inefficiency and ineffectiveness, often leading to less-than-ideal financial and medical outcomes.
From the business perspective, these diminished outcomes include lost revenue, increased expenses and, ultimately, less-than-expected net income.
From the medical perspective, these inefficiencies can suspend patients--often when they are most vulnerable--in a web of internal intricacies that do nothing to improve the healthcare provided to them.
One possible solution to getting our house in order is to integrate the key functions of contracting, prehospital coordination, medical management and revenue capture to better coordinate the processes of--and payment for--care.
By doing so, caregivers and management will have a better understanding of the parameters under which we operate because:
To make this occur, leadership is key to successful change. At Catholic Health East, leadership for this plan is being assigned to a senior physician executive as the person most able to integrate medical management into the processes of payment and finance.
The rationale for a clinical leader acknowledges the importance of patient-based functions (case management, utilization review, resource consumption and quality) to successful performance under managed care.
Most acknowledge that these elements have not been well integrated into the hospital revenue cycle to date.
Catholic Health East is attempting to show that integrated patient management can be a more effective way to operate.
At three of our Regional Health Corporations, we are conducting demonstration projects built around the premise of coordinated functionality in business and clinical processes.
While intuitively optimistic, we have no data as yet to confirm our hypothesis. We plan to observe the results over 12 to 24 months, using financial and clinical outcomes to gauge the results.
It is our hope that integrated medical and financial management also will allow for greater focus on patient outcomes and move us away from cost controls based on staffing ratios and resource reductions.
We have taken these important steps, recognizing that we have within ourselves the opportunity to make healthcare better and more efficient.
Although the "stars" won't provide the answers, time and hard work will.
Richard Afable, M.D., is executive vice president and chief medical officer at Catholic Health East, based in Newtown Square, Pa.