In 2007, Danville, Pa.-based Geisinger Heath System partnered with one of its payers, sister company Geisinger Health Plan, to launch a quality improvement initiative called Personal Health Navigator. The program, which assigns patients medical homes with the sickest 20% also receiving nurse case managers to coordinate their care, was employed to test whether a different model of care could improve the health systems productivity.
Dealing with personnel issues
To cut costs, systems seek ways to boost production, such as streamlining services
What Geisinger discovered is that the new approach not only improved patient outcomes, but also saved the provider and payer money, said Tom Graf, chairman of the systems community practice service division. The exercise ultimately shifted the concept of productivity away from an esoteric set of staffing numbers and output metrics quoted by upper management and moved it toward clear patient-service and financial-gain goals that all Geisingers health system and health plan employees could understand and commit to accomplishing.
Its paying for valuethe combination of the cost of delivering care in conjunction with outcomes, Graf said. Assessing value, he added, may be a better measure of productivity than calculating how much time it takes a given number of employees to accomplish certain tasks.
Geisinger isnt the only healthcare organization questioning old productivity formulas and testing new ways of measuring how efficiently it accomplishes goals. Other providers and payers are also putting more emphasis on tethering healthcare outcomes and costs to one another when determining whether their organizations are adequately productive. When we talk about productivity and whether you get the work done, were asking, Are you meeting needs and being high-functioning even while youre addressing financial issues? said Wes Champion, senior vice president of Premier Consulting Solutions, a division of the group purchasing and healthcare quality-improvement organization Premier.
To that end, a growing number of insurers, for example, seem less interested in defining productivity by the percentage of premium dollars that goes toward paying provider claims vs. the percentage that goes toward covering administrative costs. Instead, they are looking at whether their efforts to manage beneficiaries health are resulting in better patient outcomes while simultaneously holding down service-delivery and premium costs.
Redefining and revamping staffing models are part and parcel to achieving such new productivity goals, said Anna Silberman, vice president of insurer Highmarks Preventive Health Services and Clinical Client Relations divisions. Over the past year, Highmark has added about 200 employees to its clinical and customer service staffs in an effort to lower overall costs and improve the health outcomes of its beneficiaries.
The additions include registered dietitians, nurses and psychologists who run diabetes management, smoking cessation and other disease prevention programs.
What that means is were providing more service at a deeper level, Silberman said. In the long term, those services save us money. They save us preventable critical-care situations.
Highmark initially rolled out its expanded wellness services internally to test whether such services could help lower costs and improve the productivity of its own staff. In February 2008, the insurer published a study in the Journal of Occupational and Environmental Medicine showing the program saved the company $1.65 on healthcare expenses for every $1 it spent on employee wellness programs. The effort culled a $1.3 million savings on healthcare spending over four years, according to the study.
But while staffing productivity may be a universal concern among healthcare providers and payers alike, there is no set blueprint for becoming more productive. Under pressure from the economy and healthcare reform efforts that seek to align reimbursement levels with quality of care, companies are testing a variety of modelsfrom retraining to cutting or adding staffin an effort to improve productivity, industry experts said.
Most hospitals are part of larger systems, and Ive seen a number looking to streamline their shared services, said Paul Osborne, a managing director at the healthcare consultancy Huron Consulting Group. Those would be areas like marketing, finance, materials management and human resources. By consolidating nonclinical areas, Osborne said that hospitals are able to shift more resources toward caring for patients and efficiently moving them through the hospital, which can save money through prevention of never events and increase reimbursement by facilitating greater patient volume.
Other providers are eliminating clinical services that arent turning profits as a means of trimming staff and cutting costs, said George Whetsell, a managing director with Huron. Theyre deciding whether certain programs are in line with the hospitals mission. Its a big issue. There are programs like dialysis and diabetes care that the community may need, but the services arent necessarily well-covered, Whetsell explained. From an economic standpoint, providers cant jeopardize the entire hospital for one program.
Still, other providers continue to revamp their care-delivery systems in an effort to improve productivity. Geisinger, for example, began testing its Personal Health Navigator program in 2007 with patients at its Lewistown and Lewisburg community practice facilities in Pennsylvania. The pay-for-performance program required the providers to rework their clinical staffing models. The focus wasnt on reducing staff, but employing the right mix of clinicians and other workers needed to best manage patients health, Graf said.
To facilitate the changes, Geisinger Health Plan made an upfront $200,000 investment in the initiative. That money financed a variety of activities, including hiring registered nurse case managers to coordinate transitional care for patients moving from hospital to home, monitor medication and home monitoring devices and provide chronic disease management education. The participating provider sites were also required to undergo medical-home training and certification through the National Committee for Quality Assurance in order to qualify for certain performance improvement payments. Our nurse practitioners and other staff have opportunities to get bonuses as well, Graf said of the program.
In the first year, the two sites reduced their combined hospital admissions and readmissions by 20% and 50%, respectively, Graf said. The effort realized more than $400,000 in savings, half of which went to reimburse the payer for its initial investment and the other half to providers for meeting specific quality metrics.
Geisinger expects future savings to translate into lower care and premium costs for the health plan and its beneficiaries.
The discussion for the health plan now is: How do we transform these savings into premium reductions? Graf said. Our top sites have negative cost trends. We spent less this year than last year on a per-member basis caring for the same patient population. To that end, Geisinger Health Plan is rolling out its Personal Health Navigator program to the remainder of its facilities and has already contracted with four non-Geisinger provider sites to adopt the program.
Last year, Ohio-based 469-bed Summa Health System began tackling staff productivity issues by looking at its two largest emergency departmentsSumma Akron City Hospital and Summa St. Thomas Hospital, also in Akron. Together the departments handle more than 100,000 patient visits annually.
One of the biggest challenges Summa faced, said Brant Russell, system director of emergency and trauma service line, was preventing patient-processing bottlenecks at certain times of the day. Even while the emergency rooms had more than enough employees to handle their patient loads, they still experienced daily problems with crowded ERs. We discovered we had too many resources taking care of our patients, but not necessarily the right resources at the right time of day, Russell said.
Fixing the problem entailed changing shift setups, reconfiguring the makeup of the teams staffing the emergency departments, and requiring some clinical staff to gain new skills and take on additional responsibilities.
In addition to ER physicians and RNs, Summa had previously staffed its ERs with nursing assistants, ER technicians and paramedics. Because their skill sets were so divergent and specific, however, Summas hospitals werent able to reduce the teams to one or two support workers when emergency department activity slowed or appropriately staff up without going into overtime hours when patient visits increased. Summa addressed the problem by having paramedics take over duties previously handled by ER technicians and nursing assistants, Russell said. Over a period of a year, there was a lot of attrition. We had a handful of employees who went into nursing school or paramedic training.
Summa also staggered its shift schedule so that more clinical staff is present in the ERs between 11 a.m. and 11 p.m., when patient volume is heaviest.
Having more highly skilled workers meant salary costs for the ERs increased, Russell said. But, the system ultimately saved money because it now uses fewer overtime hours, particularly among the nursing staff. The new team approach also freed up nurses to spend more time with patients. That, Russell said, has improved the quality of care at the two ERs. Based on productivity benchmarks established by healthcare solutions company Thomson Reuters, Summa officials estimate that the changes have translated into a roughly $4 million savings to the system.
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