With violinists strolling the lobby, fresh bread baking in the hallways and an aromatherapist handing out flaxseed-filled eye bags scented with lavender, Windber Medical Center in rural western Pennsylvania is hardly a typical, traditional American hospital.
The 67-bed hospital in Windber, an old coal-mining town with a population of about 4,500, is different in a lot of ways, carving out a new approach to healthcare that encompasses everything from architecture to attitude. In addition to soothing features such as fresh flowers, water fountains and aquariums, Windber offers patients a wide range of complementary or alternative therapies, including yoga, meditation, tai chi and reiki. (Pet therapy was discontinued last year when the owner of the friendly dogs used in that relaxation technique relocated.)
It's all part of a patient-care philosophy called Planetree, a holistic system that promotes the emotional, spiritual, social and physical health of patients while allowing them to be more actively involved in their course of treatment. As a way of "humanizing" healthcare, Planetree mixes complementary therapies with conventional treatments into something of a healthcare hybrid.
"The magic words are `patient empowerment,' " says Nick Jacobs, Windber's president. "Planetree says, `patient-centered care.' When the patients arrive, they don't have to leave their dignity at the doorstep. Basically, we're offering a degree of care that's not normal."
Controversial and a bit idiosyncratic in many ways, Planetree, which was created nearly a quarter-century ago in San Francisco, has struggled almost since birth to establish itself in an industry notoriously resistant to change. Even despite its recent growth in membership, Planetree remains on the periphery of the medical community, an outsider with comparatively little national impact and a slim roster of 61 dues-paying hospital members, including three that officially will join the alliance Sept. 1.
Still, that number, which Planetree officials expect will continue to grow, represents a big jump from the mid-1990s when the not-for-profit group was stalled at 15 affiliates.
But although advocates speak about the concept like true believers, it's a hard sell for many others.
"It was a hot topic about eight or 10 years ago," says Daniel Fell, a hospital marketing expert and a partner at Daniel+Douglas+Norcross, a Chattanooga, Tenn., consulting firm. "There was a fair amount of buzz in the press. Then it kind of went away. But, like a lot of things in the healthcare industry, we see things go in cycles. More and more hospitals are looking at this softer side, designing facilities that are more patient-sensitive, which might help Planetree expand. Still, when you're talking about alternative care, that's an issue that's way down on the list of priorities for healthcare CEOs."
Selling the doctors
In addition to concerns about reimbursement for alternative and complementary care, most of which is not covered by insurance, many hospital executives are grappling with other priorities that tend to diminish interest in Planetree membership, including overall budgetary constraints in a weak economy and fears that such radical changes will trigger a revolt by entrenched medical staffs.
How tough is it to persuade doctors to accept change? Diane Pringle, who helped coordinate Windber's transition to Planetree in 1999, says most of the medical staff couldn't even handle a change in paint color much less the addition of therapies such as reiki, which is akin to therapeutic touch.
"The first thing we did was change the colors of the walls," recalls Pringle, who is Windber's chief nursing officer and the executive director of its Joyce Murtha Breast Care Center. "And that set the doctors up in arms--they couldn't believe we were changing the colors (from white to an off-white cream color). These are guys who save lives every day, but they were concerned with the color of the paint. In fact, they felt that if they allowed one little change, what are we going to do next?"
With the addition of complementary therapies, Pringle says with a laugh, the reaction among doctors was even more extreme: "Oh boy," she says, "a couple of them thought it was the devil's workshop. They drove us crazy. They were very much against it. We had to ease this in."
Adds Jacobs, "The typical hospital is filled with individuals who are extremely successful in life due to their analytical, mathematical and scientific background. They don't want to deal with this soft and fuzzy stuff."
But resistance from the medical staff has been only part of the problem in transforming Planetree into a national brand.
So far, at least, Planetree has been unable to demonstrate a broad range of objective financial or clinical benefits from this patient-centered way of doing business. Though several affiliated hospitals cite figures that show increased profits, higher gross charges or even better outcomes in some cases, it's difficult to definitively attribute those improvements to the changes shaped by a collaboration with Planetree.
In one study conducted during a six-month period from 2000 to 2001, a University of Connecticut graduate nursing student compared patient-satisfaction surveys at 12 hospitals before and after they joined Planetree. While scores increased for eight facilities, including one that jumped by 14%, two remained the same and two others saw declines.
The author, Sheila Iacono, writes: "This study provides a snapshot of the positive impact of Planetree, but it was not broad enough to document statistically significant relationships."
Susan Frampton, Planetree's executive director, says the Derby, Conn.-based organization does not track its own members to compile concrete statistics that might highlight the operational efficiencies or revenue gains associated with Planetree. Because many of the hospitals have joined so recently, she notes, there's little evidence to provide reliable comparisons.
But she says a considerable amount of anecdotal evidence, such as Iacono's study, appears to indicate that patient-satisfaction levels improve for Planetree affiliates. More research will be conducted, Frampton says.
"I'd really say that we measure our effectiveness more uniquely, for each hospital," Frampton says. "Are they meeting the goals they set for themselves in terms of progress, patient satisfaction, employee satisfaction? We've just begun to try to coordinate some of that data."
The definitive study
Jacobs says a study now being proposed by Wayne Jonas, M.D., a national authority on alternative medicine, might help to determine if such therapies have positive effects on patients in Planetree facilities. He believes Jonas' proposal for a federally funded $2 million study, which probably will include Windber along with other facilities in an effort to gauge the overall impact of alternative care in medicine, is at least one small step in an effort to reinforce claims that Planetree is good for patients seeking a somewhat unconventional approach to care.
"I can't tell you, scientifically, that if you give people flaxseed-filled eye bags and you rub your feet and you pray with them, that they're going to get out of here faster," Jacobs says. "But it certainly looks to me like it's having that kind of impact."
Jonas, director of the Samueli Institute for Information Biology in Alexandria, Va., and the former director of the Office of Alternative Medicine at the National Institutes of Health, says he wants to try to identify the "components of an optimal healing environment."
"Are there characteristics of an environment that seem to facilitate healing, and if there were, would it reduce costs and get people out of the hospital earlier?" he asks.
But critics such as Stephen Barrett, M.D., a retired psychiatrist in Allentown, Pa., who heads Quackwatch, a not-for-profit organization designed to "combat health-related frauds, myths, fads and fallacies," questions whether any such study can objectively measure the impact of alternative care in a hospital setting.
"What are you going to measure for outcomes?" Barrett asks. "If you want to do an outcome study, you'd need a control group." He also ridicules alternative care--a key element of the Planetree philosophy--as little more than a publicity tool that borders on bad medicine and might even endanger patients.
" `Alternative' and `complementary' are marketing terms," says Barrett, who has led a highly public battle against these therapies for years. "What's happened is that many places have thought they could be more marketable if they could adopt the marketing terms (for these therapies). Look, if something is useful and you add it, it's OK. If it's not useful and you add it, all you do is simply up the expense."
Barrett may dismiss it as a needless cost center, but complementary and alternative medicine is quickly being forced into the mainstream through increasingly routine use by millions of Americans. Estimates vary, but consumers spend more than $21 billion on these once-exotic services, many of which are now part of the "integrative" care centers at scores of American hospitals. Cynics notwithstanding, Frampton says these offbeat services simply illustrate how Planetree caters to the deeply personal needs of today's hospital patient. In time, she believes, the addition of these services will only help promote the Planetree model and fuel its expansion.
Planetree has faced a largely indifferent hospital industry since an Argentine woman named Angelica Thieriot founded the movement in 1978, describing it as an alternative to what she viewed as the impersonal, bottom-line business model that dominates many U.S. hospitals. She named it after the tree--also known as a sycamore--where Hippocrates taught the first medical students in ancient Greece.
By 1997, Planetree, all but dormant as a business concern, had just 15 dues-paying members and few prospects for growth. It was purchased by Griffin Health Services Corp., parent of 160-bed Griffin Hospital in Derby, Conn., a Planetree affiliate since 1992. Griffin acquired the name in a noncash deal, assuming about $100,000 in debt, and moved Planetree's headquarters from San Francisco to Derby.
Launching a far more aggressive marketing approach in recent years, Planetree has slowly spread its wings, adding scattered affiliates across the nation. By 2000, membership had risen to 32 hospitals, growing to 49 the next year before reaching its current level. William Powanda, vice president of Griffin Hospital, says hundreds of hospital executives from around the world have visited Griffin and other Planetree hospitals. Comparatively few have been willing to commit with cash--at least until now.
"We've far exceeded our expectations (in new members) when we took on Planetree 31/2 years ago," Powanda says. "I think it's totally related to the surging tide of healthcare consumerism. I think the Planetree model of patient-centered care is responding more and more to the increased expectations of consumers."
In past years, Planetree charged affiliates $20,000 for the first year and $15,000 each year thereafter, a fee that covered all membership benefits and on-site consultation. Fees now are based on bed count--$12,000 per year for hospitals with fewer than 200 beds, $15,000 for midsize hospitals and $20,000 for hospitals with 350 or more beds. Most hospitals also pay a minimum of $5,000 in "prepaid" consulting fees for a variety of services that Planetree staffers provide. Planetree posted total revenue of about $565,000 in fiscal 2001--a 54% increase over the previous year.
Frampton says Planetree already has eclipsed its target of 56 affiliates by the end of the organization's fiscal year on Sept. 30. Asked what she predicts in future market share, Frampton replies, "I can see 500 (affiliates) down the road."
She dismisses the notion that most healthcare executives reject the Planetree model because they don't think it will make any money.
"It really depends on what hospital executives are motivated by," she says. "If one of the things they're compelled to do is increase patient-satisfaction ratings, then this is certainly a strategy that makes sense. If they're motivated by the fact that they're in a competitive market and they want to differentiate themselves, this makes sense. As far as (reimbursements for alternative and complementary care), it's absolutely true that most people pay out of their pocket. But research is showing a growth in usage that is pretty phenomenal."
Among Planetree's most recent additions: 107-bed Williamsburg (Va.) Community Hospital, which signed up on June 1 and expects to slowly adapt its staff to the new business model. Eventually, the tenets of Planetree will be fully integrated in an outpatient center and replacement hospital six miles from the current site.
So far, Williamsburg, moving cautiously in its first two months, has added pet therapy, art and music, among other modest selections from the Planetree menu. Les Donahue, the hospital's president and CEO, says he believes Planetree's growth in the past several years signals a growing acceptance in the industry.
"I think we are on the beginning edge of a wave," he says. "I think hospitals are looking for ways to better serve their patients and to look at the entire patient. I think we're on the cutting edge of something that may become far more prevalent."
Although Planetree's vaguely utopian philosophy seems more suitable to smaller facilities, it is now featured, in widely varying degrees of implementation, at several large facilities in metropolitan areas. They include 992-bed Beth Israel Medical Center, New York, where two inpatient wings with a total of 74 beds incorporate the Planetree philosophy; 701-bed Albert Einstein Medical Center, Philadelphia, where it has been added to the Minerva and Fred Braemer Heart Center; 594-bed Hackensack (N.J.) University Medical Center, the largest provider of inpatient and outpatient services in New Jersey, with a complementary medicine program that includes therapeutic massage, meditation, yoga, hypnosis and reiki; and 492-bed Northside Hospital, Atlanta, which offers Planetree-style additions such as "healing sounds," "thoughts for the day" and mentoring programs that help guide individuals down the path to nontraditional care.
"A lot of the hospitals are in different stages," Powanda says, noting that some of the larger facilities do not offer an expansive menu of alternative or complementary therapies. "One of the things we've always said is: This is not a destination, it's a journey."
Longmont (Colo.) United Hospital, in a farming community about 40 miles north of Denver, is among the most recent hospitals to fully integrate Planetree's philosophy into its physical plant. A $22.8 million structure that opened with great fanfare in January 2000, it features 66 single rooms, a lobby piano, lots of art on the walls, big windows and open nursing stations to provide patients with a sense of inclusion. Among its many "complementary options," the hospital offers herbal therapy, massage, acupuncture, pet therapy and reiki.
Despite Longmont's gleaming example, Griffin remains the prototype of a successful Planetree facility. The 127-bed hospital, which was completed about two years after Griffin joined Planetree, has won several major design awards, including an honor in 1996 from Modern Healthcare, and embodies all the qualities of the patient-centered philosophy. It includes home-like kitchens for patient and family use, lounges with saltwater aquariums and music rooms with pianos. Musicians, magicians and caricaturists regularly entertain patients, who also have access to a pet therapy program. There are also hotel-style amenities such as room service.
"This isn't about architecture and design," Powanda says. "It's about the transformation of a culture. Any hospital can build a Planetree-type facility. But unless you have the passion and commitment to this kind of a model, you're just going to have a new facility that is perhaps a little more consumer-friendly than the others."
As headquarters of the movement, Griffin is also working to establish itself as an example of how Planetree's patient-focused philosophy can yield positive results, according to Frampton and Powanda. In January, for instance, Fortune named Griffin one of the 100-best companies to work for in America for the third consecutive year. What's more, they say, inpatient admissions were at their highest level in nearly two decades, outpatient services have increased by about 40% in the past three years and patient-satisfaction scores are better than ever before, increasing to 97% in 2001 from 83% in 1994.
Powanda is convinced the affiliation with Planetree is largely responsible for a remarkable turnaround in the fiscal fortunes of Griffin, which was in danger of shutting down in the late 1980s because its aging building--the oldest in the region--couldn't compete in a tough market that includes seven hospitals within 18 miles, including New Haven. Faced with a $1.8 million loss in 1989, Griffin was forced to lay off 42 employees, outsource the hospital laundry and close several patient services. After adding 23 new physicians to the medical staff, the hospital ended the year with a $270,000 loss and a new outlook on the future, exploiting any way to differentiate itself from its many competitors.
"There certainly is a belief that if Griffin had not found Planetree . . . it would not have survived," Powanda says.
Griffin is now one of the fastest-growing and most successful hospitals in the state. Patient admissions have swelled by about 30% during the last 21/2 years, more than tripling the average increase at other Connecticut hospitals, Powanda says. Net income reached $3 million on about $69 million in patient revenues in the fiscal year ended Sept. 30, 2001, he says.
Similarly encouraging numbers are cited at Windber, where Jacobs made the Planetree affiliation a top priority immediately upon taking over the job in February 1997. Something of an iconoclast himself--he's a former professional trumpet player who switched to a career in healthcare at age 40--Jacobs argued successfully to board members and staff members that drastic change at the hospital was the only way to address the needs of today's demanding consumers, even though the hospital was making money at the time.
For instance, each day at Windber, keen attention to the patients' every need extends to the pleasing and pervasive aroma of fresh bread, cooked twice daily on carts in the hospital's hallways. There are almost no limits to visiting hours--family members and friends can spend as long as they like with patients, bringing along pets if they so choose. Cellists play in the lobby. Violinists stroll the hallways. About 122 ministers, priests and rabbis are associated with Windber, providing a "spiritual component that is always available" to patients, Jacobs says.
Since Windber joined Planetree, Jacobs says, gross charges at the hospital have doubled to about $60 million annually. Overall financial results, though, have been mixed. After posting net income of $2.4 million in 1997 and $1.5 million in 1998, the hospital lost about $207,000 in 1999 and barely broke even in 2000, says Linda Fanali, chief financial officer. In 2001, Windber earned about $242,000, she says.
But Jacobs credits the Planetree philosophy at least partially with several successful measures, including an increase in emergency room visits from 6,400 in 1997 to 7,500 in fiscal 2002 ended June 30, and a rise in lab procedures during that period, from 173,000 to 240,000. He says he believes the addition of complementary medicine, along with a more caring attitude, combined to help boost business.
This is the kind of evidence, Jacobs says, that eventually will earn Planetree a far larger audience. Just how large an audience depends on whether that evidence is convincing to skeptical hospital executives.
"(The healthcare industry) needs to be able to say definitively that, from a study done at Planetree hospitals, your lengths of stay will go down, your infection rate will go down and people will not die because of the way they're treated in a facility like this," Jacobs says. "And you'll save money and make money because more people will want to come to your institution. You do this, and I guarantee you they'll be lined up at the doors to join."