This morning I had an experience that could only be described as Transformational. My presentation to the World Health Care Congress 2nd Leadership Summit was finished yesterday afternoon and it went as well as could be expected. We discussed HCAHPS, Employee Engagement, Patient/Family Partnerships, Evidence Based Design, and how to appropriately staff the various seats on the proverbial bus.

My flight was not scheduled until Friday, so attendance at the morning sessions seemed like a viable option. Listed on the speaker’s schedule was B. Joseph Pine ll, and his topic was “Work is Theatre and Every business a Stage and Authenticity: What Customers Really Want.”

As Mr. Pine went through his 55 minute presentation, my initial reaction was “Yep, knew that; heard that before; understand that,” but then, during the last five minutes of his prepared remarks, Joe hit us between the eyes with that thing that had always been there but had never become completely clear to me during the past two decades.

He asked us what people wanted when they joined a health club, went to business school, or a psychiatrist? The answer, of course, was that they were looking to be transformed. Each and every day for a dozen years, I have watched this process and never grasped the nature of this metamorphosis.

One of the participants made a point of asking why it was that a person could come to a hospital, have open heart surgery that changed or even saved their life yet would not donate even $200 back to the hospital during the annual fund drive? Yet that same person would leave their entire estate to a university that they had attended fifty years earlier? What was the difference? In both cases something dramatic had happened, but in the case of the open heart surgery, it was just seen and presented as a service or at best an experience.

The university however, provided a significant transformation of the life of that person. This simple description explains why so many open heart patients go back to doing exactly what they had done in the past, and end up back on the table two or three more times. It was seen by the patient as a service or at best an experience.

With this in mind, my observations of what happened to those patients who participated in the Dean Ornish Coronary Artery Disease Reversal Program was that, for the most part, they had joined that program looking for a transformation, and that indeed is what they found. Most of the participants who had come there seeking a total change and a new way of living a more healthful life were transformed by the program. They no longer perceived of themselves as being victims of their health.

How does this all play out in the field of healthcare? WalMart is going to produce a commodity, electronic health records, competing with WalMart on any level will prove to be a fruitless journey because they have mastered the world of commoditizing services. The Starbucks experience may get customers in the door time and time again, but what is it that we need to do that will produce grateful, loyal, generous customers or patients forever? Provide a transformation.

For those of us who are getting this, begin to look at your hospital, your practice, your business as more than just a service and much more than an experience. Think of what you do as providing the tools necessary to transform those with whom you are working, and present your product, your passion, your involvement with the client, the patient, the customer as a means of transforming them. Dedicate yourself to helping them reach their goal of changing their life in a positive way forever, and see where that leads you. TRANSFORMATIONAL CHANGE is what we all seek at some level. The product: To help us make our lives better.

Hospitals and health professionals rate as some of the most highly scrutinized organizations and businesses in the United States. Hospitals and physician’s offices, durable medical equipment companies, and home health agencies are under the magnifying glass of federal, state, and local government inspectors.

Some would say that this is with good reason as we scrutinize the numbers behind the analysis. As annual health care costs continue to ascend toward a projected $2.4 trillion (16.6% of the GDP*) and with health coverage a major political issue this year, the potential of a $72 – $240 billion annual loss (3% – 10%** of the total health care outlay) to health care fraud and abuse and mistakes, remains a major issue for private citizens, corporations and government agencies.

In order to put this in perspective, the overall numbers at play relative to the $2.4 trillion healthcare budget are significant. The monies estimated to be consumed inappropriately reach a staggering $236 – $787 loss per capita, or enough money to insure up to 30.5 million Americans, or 65% of today’s total uninsured population of 47 million.

The pendulum swings both ways in this scenario, however, as these issues occur on both sides of the provider and healthcare user coin. The Centers for Medicare and Medicaid began RAC audits utilizing Medicare Recovery Audit Contractors (RACs) to recoup $980M from Providers in demonstration projects in California, Florida and New York. To say that this system is fair, equitable, and was well conceived would be an exaggeration because the auditors employed to do these audits are paid a percentage of their findings, and that inherent conflict alone stresses the validity of this arrangement on many levels.

A few specialty healthcare finance based organizations like my new employer, SunStone Consulting, concentrate in preparing hospitals for these inevitable visits by the RAC auditors. When these specialty companies do their work appropriately there is no reason for the RAC auditors to destructively move through the billing and medical records departments of each hospital.

The very essence of the problem is that, no matter what the intent, any time federal dollars are involved, these investigating authorities appear to have already made a determination that the problem or mistake was a purposefully fraudulent act whereas, in fact, it is quite possible that it was an oversight, an honest mistake, or an inappropriate key stroke.  To determine the validity of these situations in which fraud, abuse, and overpayment are suggested, research through organizations such as HealthCare Insight specialize in identifying, preventing, and investigating both provider and patient fraud health care claims.

Companies like this typically provide private and public sector health care claims payors (Health Plans, MCOs, Insurance carriers, TPAs, Medicaid, Medicare, etc.) with a comprehensive suite of clinically validated fraud and abuse surveillance solutions designed to maximize claims administration accuracy and minimize payment waste.

Interestingly, with the bailout bills from both the Bush and the Obama administrations being activated on an ongoing basis, one must stop and ask how much each one of those nearly trillion dollar initiatives will cost to audit, investigate, and qualify. It’s obvious that the hands off theories did not work, and now we will see the pendulum swing back as far as it will to attempt to  over correct the sins of the past.