My Facebook friend, Anne Zieger, editor of Fierce Health Finance, wrote a compelling piece the other day regarding the potential demise of hundreds of hospitals. Her prediction is based upon some very valid financial realities, and we are witnessing them locally as well as nationally. Not unlike the little banks in our area that seemed to have been insulated from Wall Street’s collapse, some of these national problems seem to be washing over some of the smaller hospitals with relatively minimal damage. Yes, many of us have seen as much as a 10% decrease in elective, outpatient procedures.

In fact, while visiting a really upscale mall for a photo session with my two year old granddaughter, Lucy, an employee engaged me in a conversation about the rotten economy. About five minutes into the conversation, she indicated that there are currently 150 stores in the chain for which she works, and that only five percent of them made budget last month. Portrait pictures must fall into the category of a luxury as their business is severely impacted by this economy. More directly, however, she indicated that she needed stitches removed the other day, and that, “she did it herself” rather than spend the $20 co-pay.

So, are we seeing decreases in important tests? Are we seeing patients avoiding emergency room visits? Are we seeing patients cutting their prescriptions in half? Yes, to all of these questions. Anne, however, seemed to be talking about the “big boys,” where their millions or billions in investments have recently tanked. If you are so big that your income from running the hospital is not a major source of protection, and your income from your investments is propping you up, then the problems begin to manifest themselves exponentially.

“Some hospitals are responding by digging into their investment income more deeply than usual, using it to finance capital projects, or even meet operational needs. Others are issuing bonds with the scary codicil that they’ll buy them back if finicky investors want to dump them,” states Zieger in her column.

She further goes on to explain that “both of these situations put a huge squeeze on hospitals’ long-term viability. One robs from their long-term assets to solve medium-term problems, while the other puts the hospitals at risk of being bled dry by investors who get spooked.”

Well, wouldn’t ya know? Yes, we are seeing a few challenges due to decreased electives, but not because we were living off of our investments. The other good news is that, because we froze our fixed pensions several years ago, we are seeing very little impact upon them from the huge drop in those investments as well. Unlike many of our larger peers, neither of these issues is similar. Between the drops in the market, the loss of pension funds, the decrease in electives, and the down-grading of their viability by the bond markets, their challenges look galactic in size compared to ours.

Sometimes smaller is just safer.

What do you do when you don’t have enough money to do what you need to do for you or your family’s health? I know, it’s a redundant question? You go without, delay or borrow from your future in the form of debt. According to Reed Abelson and Milt Freudenheim of the New York Times in their recent article Even the Insured Feel the Strain of Health Costs, as employers struggle to keep up with mounting costs to cover their employees, the average cost of an annual health care premium for that employee has nearly doubled since 2001, from $1800 to nearly $3300 a year.

Example after example is delineated in the Times article regarding those individuals who just can’t afford the challenges presented by the rising food and gasoline prices. Those featured families and individuals skip meds, wait longer to take sick children to their pediatrician or are facing staggering bills from health care institutions. According to the accounting firm, Deloitte, the average American income that goes toward health care expenses is now approaching 1/5 of their total household spending annually.

As a hospital administrator, it is never easy to listen to the general public throw stones at the medical industrial establishment, but when it comes to fancy, esoteric diagnostic tools, unproven drugs that can cost $6000 a dose or the very best physicians known to man, bring ‘em on becomes the hue and cry as we, the health care consumer wants nothing but the best for ourselves and our families. This is America. We deserve it.

Of course, if you are looking for elective surgery and you happen to live in England, you will wait on average 1.5 years for that intervention, and if you are in Scotland, it will be very close to 2.5 years before that same surgery is available.

My Democratic friends embrace the hope of the future through proposed health plans that insure the masses. My Republican friends warn of the horrible train wreck those plans will cause in hospital emergency rooms as every George, Dick and Conde will make their way to our hospitals with no barrier in place to prevent them from over running our already strained bastions of care.

Regardless of your political bent, it does seem unconscionable that we have nearly 48,000,000 uninsured accounted for by the government. Most of these uninsured are young, single moms and kids who either can’t or choose not to vote. (No one has ever believed that to be a co-incidence.) This figure also does not include the underinsured and quite possibly may not include any of the 50,000,000 illegal aliens. We are the only industrialized nation in the free world that does not have a true health policy for our citizens.

So what is the answer? The iron triangle of the best, fastest and cheapest health care is something that cannot exist in a system that is still hanging on ever so completely to an acute care based model when the vast majority of our health care challenges are now chronic care cases. We 78,000,000 Baby Boomers are taking more pills to control our varied maladies than existed in total just 20 years ago. Ask your pharmacist how many drugs there are now compared to 1988.

One very real answer to this health problem sometimes seems too simple. Our nearly $2 trillion in yearly health care expenditures includes less than four percent of its total dollars for preventative care. Much of our problems are about wellness.

So, wash your hands, drop some weight, exercise, cut out the saturated fats, stop smoking and live a less stressful life by doing something other than stare at the television…or else just wait for that little blue pill that will help you be skinny, tan and sexy, and then sell the family car to pay for it.

Back in the 70’s, competitive marching bands came into vogue in Western Pennsylvania. Let me explain the before and after of this phenomenon: Before there were competitions, bands were made up of nearly 10 times more students than they typically have today. My bands ranged in size from 120 to 185 students. Once competition came into play, the borderline students were not able to survive. Consequently, it is not unusual now to have 20 students or less in a band.

What’s happening in medicine and in health care overall? The Government is taking a three-pronged approach to improve quality in health care:

1. They are pushing quality through public reporting. (Check a website near you.)

2. Enforcing quality through the False Claims Act. (Check a prison near you.)

3. Incentivizing quality through payment reform. (Check a checkbook near you.)

Senator Chuck Grassley is quoted as saying, “Today, Medicare rewards poor quality care. That is just plain wrong, and we need to address this problem.”

HMO’s are currently embracing “pay for performance” plans for physicians and hospitals. Medicare is introducing value-based purchase plans. Medicare is proposing the linking of quality outcomes to physician payments.

As I have written before, hospitals will no longer be paid for hospital acquired conditions. That seems like a rather simple fix, but to appropriately determine if the condition was not acquired at the hospital, extensive testing must be added pre-admission at considerable costs to the hospitals.

James G. Sheehan, Medicaid Inspector General of New York said, “We are reviewing assorted sources of quality information on your facility to see what it says and if it is consistent. You should be doing the same.”

Except for the financial implications, not unlike my competitive band story, the goal was to work toward perfection. The public reporting of quality of care is intended to:

1. Correct inappropriate behavior

2. Identify overpayment’s

3. Deny payments

The False Claims Act, on the other hand has different goals. When asked how he viewed the False Claims Act, Kirk Ogrosky, U.S. Deputy Chief for Health Care Fraud said, “You will see more and more physicians going to jail.” I guess the prisoners will be receiving better care.

Where’s it all going? Competitive band. Will it improve health care delivery? Probably, for the patients who can find the few docs and hospital that will be left? I recently had a conversation with a young computer specialist who took care of physician practices. He said, “Doctors and hospitals haven’t figured it out yet, but they are simply becoming data entry centers for ‘Big Brother’ as the facts and figures are accumulated to be used against them any way the payers decide to move forward.”

Looking back at the school year that included gym class twice a week for the entire year, rich courses in music and art, and remembering a time when priorities included those classes intended to make every student well rounded, we have to ask, “Is education today better?”

Maybe this is all too complicated to get our arms around, but if there are 78 million Baby Boomers, and the Medicare Trust Fund is heading toward bankruptcy, then we probably will see every rule in the book being applied to keep from paying out money, because there is simply not enough money to go around.

Will health care improve? Once we understand that technology is not the end all and cure all that creates healing; once we endorse prevention, wellness, optimal healing environments, and systems approaches to health and wellness, health care will improve. I’ll bet you that it will have very little to do with the rules that are unfolding right now and much more to do with the creation and acceptance of a National Health Policy.

From the age of about eight until 20 years ago, my entire life was immersed in music, education, the arts and, in a very pure way, people in general.  It was a complex world that required a deep, intuitive understanding of the human condition on multiple levels.  In a very general way, that life, (pre-health care management) was all about systems.  

Obviously, it was never just about one or two individuals, and it was not about life and death, but it was magnificently complex in its own way. It involved working with  people to do something that was extremely challenging, that required incredible hand/eye co-ordination, and an ensemble mindset of co-operativeness that was paramount to success.  Most importantly, it required them to listen intently to each other so as to find the perfect balance, blend and intonation. 

The nuances of taking a systemic approach to the creation of music through the efforts of an ensemble in many ways have escaped our world of healing, at least until now. 

At a recent visit to my dentist, he and his hygienist were talking about the fact that the doc had just taken a continuing medical education course.  When he was asked if anything new had evolved from his class, he smiled and said, "Well, for the first time in 28 years of practice, they admitted that the mouth is connected to the body."  He went on to elaborate about the fact that each and every day he sees the destruction caused by inflammatory disease of the gums, and then told me about his attempts to communicate that information to a physician friend several years ago.  "It just didn't register," he said. 

What little we know about inflammatory disease has us dutifully brushing our dog's teeth to prevent a heart condition, yet we still do not have direct lines of communication between our primary or cardiac physicians and the the dentists who see these problems as they manifest themselves in our body.  

Someone once told me that Descartes' Treatise of Man played a major role in the imposed medical and emotional separation of the brain from the body, as it clearly took the stand that "Hospitals and physicians should take care of the body while the church takes care of the mind and the soul."

One of our scientific collaborators, Dr. Lee Hood, is famous for his work in Systems Biology.  Another collaborator, Georgetown University, is involved in the creation of a medical school program revolving around Systems Medicine, and finally, our Optimal Healing Environment collaborator, the Samueli Institute, is focused on Systems Wellness.  In spite of these wonderful leaps into what would have to be considered common sense approaches to health and life, we still sometimes miss the ensemble approach.

My recommendation? 

Maybe it would help our healers to take their place on the podium, look at every one of the 30 plus lines of music on the score, raise the baton and begin to direct their way through every nuance, inflection, and harmonious signature present in a score of music with the appropriate rhythm, intonation and accents just to remind themselves that; we human beings are basically all made up of systems as well, and those systems will not function smoothly if one is completely out of sync with the other." 

This is something that we all know intuitively.  Maybe immersing ourselves in that world for a while will help bring that concept totally back into focus.  It's all about harmony, balance and nature's perfection, and a disjointed approach to health is as potentially harmful as a disjointed approach to life.