21 years in the business

I was reflecting the other day that earlier this week (26 August 2013) marked the 21st start to a Fall semester that I have spent as a professor of healthcare management. September 1992 was the start of this journey as a first year assistant professor in the Department of Public Health at Oregon State University. I had defended my PhD on July 25, 1991 and began my search for a full-time faculty position. In retrospect, I was so very fortunate to be offered the position at OSU where I could hone my teaching and advising skills, develop as a health management researcher, and learned to connect with healthcare providers across the state. I was given the opportunity to direct first a BS degree program, then an MPH degree and finally a PhD all with an emphasis on healthcare management. In 2008, my journey took me to Washington, DC and the George Washington University where I currently work as a Professor of Healthcare Management and Leadership and direct the Master of Health Services Administration degree program. This is a truly remarkable opportunity to play a role in a program that has been in existence for 53 years and has graduated almost 3,500 students.

Over this 21 year career, I have seen this field grow and evolve primarily in terms of how healthcare is paid and the effect of payment reform on the delivery of care. When I entered the field, retrospective (fee for service) medicine was the norm in many parts of the country. The Emergency Medical Treatment and Active Labor Act (EMTALA) had been enacted by Congress in 1986.  Hospitals and physicians were adapting to the demands associated with DRG's and RB-RVS. Mergers and acquisition activity was sweeping its way through the industry with the growth and (sometimes) demise of various forms of integrated delivery networks both vertical and horizontal. Stated simply, the only constant in healthcare from the time I began my career as a healthcare management educator was change.

What I would like to do over the next several months is to look back and look forward to what I consider to be the most important changes in healthcare over the past 21 years and the ways in which educators have responded as we prepare both undergraduate and graduate students to make a difference in whatever part of the health sector they choose to work.  I invite you to submit your thoughts and ideas about the intersection of healthcare management and healthcare management education. My plan is to have two new blog entries every month. I look forward to your thoughts, comments, and reaction whether you are an educator, healthcare practitioner or an interested consumer.

Dutch Health System study tour - Tuesday

Tuesday morning was focused entirely on meetings with representatives from the Dutch Ministry of Health, Welfare and Sport.  We were met by Annemarieke Taal and Paul Thewissen who took us through the organization, financing and delivery of health services in the Netherlands.  Among the key facts shared with us were:

The Netherlands has some 16 million persons living here and there are 83 general hospitals of which 28 are more specialized along with 8 academic health centers. The Netherlands has some 26,000 physicians and 82,000 support staff.  Just under 1/3 of all physicians are general practitioners. There are just under 20 commercial health insurance companies that cover every Dutch citizen.  The Netherlands spends about 60 billion Euros per year representing just over 10% of their GDP.

Hospitals are run as non-profit entities most of which are 100 beds or more in size.  In the Netherlands, primary care physicians play a central role as the gatekeepers to the system.  24/7 access is provided through a series of "posts" that are manned by general practitioners.  Physicians are paid a fixed price quarterly based on the number of patients in their practice and will get additional negotiated monthly compensation based on providing consultations. 

The Dutch health insurance system provides care to everyone under the terms of an individual mandate. A basic group of services are provided to everyone including physician and hospital care including long term care. In 2006, The Health Insurance Act effectively expanded insurance coverage to everyone.  Insurance companies must cover all citizens regardless of preexisting conditions.  Health insurance is paid by a combination of taxes and a yearly deductible of 350 Euros.

Cost control continues to be a major problem in the Netherlands as they try to get a handle on reducing a 4-5% annual increase in health costs and health expenses are rapidly crowding out spending on other public expenses.

The bottom line for me is that despite the concerns expressed about the costs of the system, the Netherlands has an individual mandate that provides health insurance for each and every person at a GDP and per capita cost significantly less than the United States coupled with outstanding health status indicators.

Our afternoon took us to The Hague, site of the seat of government for the Netherlands.  We took the time to explore, Knights Hall (http://en.denhaag.nl/en/residents/culture-and-arts/to/Knights-Hall.htm). This one time hunting lodge was converted to the site of the Queen's annual address the third Thursday in September.  The Hague is a thoroughly charming city and I would recommend it to anyone considering a trip to the Netherlands.

Dutch Health System Study Tour - Monday

Our travels today took us to two very different hospitals.  Our first stop was to the VU (Free University) Medical Center ( http://www.vumc.com/patientcare/about/). We met Dr. Fokke Rakers, Director of Real Estate for the hospital.  They are one of a handful of academic health centers in the Netherlands.  With 713 licensed beds and over 50,000 admissions in 2009, they are one of the smaller AHC's in the country.  This is an AHC whose strategy is focused on the merger with a major psychiatric hospital, a strategic alliance with the Amsterdam Medical Center, adoption of lean, centralization of imaging functions, growth of human health and life science and network development. All of these new initiatives along with the tremendous number of new buildings on the campus are funded through internal resources and not government grants or reimbursement through insurance payments.

We learned that the Netherlands spends about 10.5% of its GDP on health care with the second best clinical outcomes and health indicators in all of Europe (behind Sweden). We were informed that the lean journey began two years ago starting in the OR. Results to date have been very positive with little or no resistance by physicians and nurses.

After the presentation by Dr. Rakers, we got to visit the new pediatrics unit.  It presents a warm, welcoming and comforting environment for children undergoing treatment at the hospital and their parents.

We then traveled to the Antoni van Leeuwenhoek Comprehensive Cancer Center (http://www.nki.nl/Research/). Their total focus in on the prevention and treatment of cancer by doing both basic and clinical/scientific research.  Their in-patient hospital has 180 licensed beds and in 2011, had 7,400 in-patient admissions and 30,700 outpatient visits. The hospital will be celebrating its centennial in October 2013. Theirs is a highly patient focused experience that seeks to provide to support patients and their families.

There were a number of interesting attributes about the Cancer Center.  All of their physicians are on salary and are on the same six step salary scale.  We learned afterwards that certain clinical specialists have the potential to earn additional revenue from various sources.  The hospital is looking to grow by 70% in 2020 and partner with an academic health center in Utrecht.  In the Netherlands, data about cancer patients and their treatment is collected on a national level and as a result, the hospital has adopted a robust operations management and quality improvement program. Another interesting piece of information was that the Dutch government and the commercial insurance companies have adopted standards related to the volume of services done and the willingness to pay for these services.  Stated another way, insurance companies will pay only if a certain minimum number of procedures are done annually.

After a brief tour of the hospital, it was time to depart for the day. Tomorrow, we travel to the Hague for a meeting with representatives from the Ministry of Health.

Dutch health system study tour

Here we are back on the road - this time in the Netherlands as part of the AUPHA sponsored study tour of the Dutch health system.  I will be blogging each night this coming week to share my thoughts and observations about the health system of this small country.  Please send me a note if you have any thoughts or questions that I might address while we are here.

What the US healthcare system can learn from Israel

Rethinking Healthcare Reform: Lessons Learned from Israel

In what seems like a lifetime ago, the United States Congress in 2010 passed and President Obama signed into law the Affordable Care Act (ACA). While the Act is certainly complex and remains the fodder of heated political debate, the basic intent of the bill is to make healthcare more widely accessible to the tens of millions of Americans who do not currently have health insurance.  The centerpiece of the ACA is the requirement that citizens purchase health insurance either through their employer or through one of several insurance exchanges.  It is reasonable to ask how a system like that might work and how other nations who have adopted similar programs have done relative to health outcomes, consumer satisfaction and eliminating or reducing health disparities.  While a number of industrialized nations provide health care through a single payer (government run) system, others have made a public-private system the model they use to guarantee health services to all their citizens. One of those nations is Israel which (as it turns out) has a lot to teach the United States on how to operate a universal health system that is based on both private and public inputs.

In close cooperation with the leadership and faculty from the Hebrew University of Jerusalem, Hadassah Hospital, and the Braun School of Public Health, seven students and two faculty members from the George Washington University School of Public Health and Health Services recently completed a two week study tour of Israel’s healthcare delivery system. The objective of the study tour was to allow these future healthcare leaders the opportunity to critically examine the organization, financing and delivery of health services throughout Israel. Through a combination of classroom and field based learning, the students discovered the following:

• ·         Israel adopted its national health system in 1995 requiring all permanent residents be provided a standard basket of services including physician care, hospitalization, prescription drugs and dental care for children

• ·         Healthcare is paid for by a combination of earmarked health tax payments, funding from the Ministry of Health and co-payments paid when services are delivered.

• ·         Four “sick funds” or HMO’s act as the insurance plan for all residents. Persons can freely choose any of the sick funds and can access any physician or hospital in the plan. The sick funds may offer supplemental coverage that is highly regulated.

• ·         Health coverage for every resident of Israel is accomplished for 8.7% of GDP in contrast to the US cost of 17.6% where there are almost 51 million without health insurance

• ·         By virtually all commonly used indicators including life expectancy and maternal and child health measures, Israel far outperforms the US.

• ·         An electronic health record ties together all the patient information for each of the four health plans and is accessible to physicians, hospitals and patients

This is not to say that the healthcare system in Israel is flawless and could not be improved.  The out of pocket costs to consumers continues to rise, there remain a number of critical health disparities particularly Israeli Arabs and peripheral populations and last year a 158 day physician strike over wages and working conditions revealed that provider working conditions must improve.

Despite the problems in Israel’s system, there are a number of important observations our students made that can have direct application to the United States and the implementation of the ACA including:

• ·         Cost control is essential particularly with respect to the payment to physicians and the reimbursement to hospitals.

• ·         The patients and their health and well being are at the heart of the Israeli system. Here in the US, the physicians, hospitals and commercial health insurance all believe that the system exists for their benefit.

• ·         An integrated electronic health record available to every one of the patients in the four HMO’s in Israel serves to reduce waste and duplication, gives physicians immediate access to clinical information and helps drive rational administrative decisions.  We are moving in this direction but progress is slow and uneven

• ·         The national standard basket of services assures that all patients, regardless of the HMO they choose, are guaranteed a uniform basic set of health services, which supports social cohesion.  Allowing each of the states to determine what services will be covered under the ACA forgoes this cohesion.

Perhaps the most important lesson learned by our students is the level of support that exists in Israel particularly around healthcare delivery.  There is an overt and covert sense that everyone is in this particular boat together and that it makes sense for everyone to have access to healthcare. In the end, this is what the ACA is trying to accomplish. All we need do is look to a small nation on the Eastern Mediterranean for an example of how to do this right.

Israel trip day 13 - 23 December

Well, this is it - our final day in Israel. We met as a group first thing in the morning to debrief the trip on a number of levels: content, culture and logistics. The comments from everyone in the group were so helpful as we begin the work of planning the next study tour to Israel. The one thing that we must do is thoroughly brief the participants about the US healthcare system if we expect everyone to be on the same page when comparing  the US system with any other. We also need to make sure that the students arrive in country first thing in the morning and then give them that day to rest and prepare for subsequent activities.

I want to be sure to thank Orly Manor, Director of the Braun School of Public Health at Hebrew University for making herself and her faculty available to us at every turn. All of the Braun School faculty are truly wonderful and dedicated teachers and scholars. Dr. David Chinitz is truly a mensch. His vision and energy gave us access to the breadth and depth of the Israeli health care system in a way I could have never imagined. He is also a passionate and inspiring teacher and is someone who I look forward to working with long into the future.  Thanks to Vardit Luzon who worked so hard to put together a travel package that came in under budget while at the same time meeting and exceeding all of my expectations.  Thanks to Nathan our guide whose encyclopedic knowledge of Israel was something to behold. Thanks as well to Sami whose skill at maneuvering our bus through impossibly crowded and busy streets was nothing short of magical.  Thanks to Laura Ochs at the George Washington University International Studies Office for all of her efforts to keep me calm and focused during the planning of the trip.  Thank you to Bob Burke, Chairman of the Department of Health Services Management and Leadership and Lynn Goldman, Dean of the School of Public Health and Health Services for your trust, confidence and commitment.

Special thanks and appreciation must go to Arthur Shorr. Three years ago, Arthur had a vision to bring a group of students to Israel and provide them with an opportunity to learn about the way health care is delivered in this very special nation. He remained persistent and focused throughout. I am glad that we gave him a chance to upgrade his Hebrew since he was speaking it like a native at the end. Arthur is an inspiration to me and I am so grateful he was here with us.

Finally, thanks to Teke, Vincent, Karen, Bijay, Morgane, Jeremy and LeMia - our students for whom this trip was intended and who were always fully engaged and energized even when it seemed like the days would never end.  The seven of you are truly wonderful and special people and without you, none of this would have happened.  Thanks to the seven of you for helping me to learn more.

So, on this early Saturday morning 24 December, let me wish all of you Shabat shalom and best wishes for a happy and healthy 2012.

Israel trip day 12 - 22 December

I have difficulty believing that we are just about done with our trip to Israel.  The last 12 days have flown by in a blur.  Today we began with a visit to the National Library of Israel which is on the campus of Hebrew University of Jerusalem. The National Library is equivalent to our Library of Congress.  It is housed in a building that is clearly too small for the collection and the many scholars, librarians and visitors that come in each year.  We spent the large part of our time in the archives and rare books section where we were treated to an up close view of a number of books that focused on the history of medicine including a first edition of the book written in 1543 by the Flemish anatomist Andreas Vesalius.

Our visit to the National Library was done too soon and we took the short walk to the Israel Museum. This is truly one of the most magnificent museums in the world that combine multiple worlds including art, culture and history.  Spending 3.5 hours at the was far too short a time to take in everything from the Dead Sea Scrolls, the extensive archaeology section, sculpture throughout the exterior, Impressionist galleries, Jewish art and life and the Second Temple Model.

In mid afternoon, we met up with David Chinitz and walked to the Brookdale Institute for Applied Social Research.  There, we were met by Dr. Bruce Rosen, Director of the Smokler Center for Health Policy Research. According to their website and verified by David Chinitz and others, "The main objective of the Smokler Center for Health Policy Research is to contribute to reforms and the development of Israel's national health services by offering objective data and independent analysis to improve the organization, delivery and financing of health services. In addition to hearing about the important work done by the Smokler Center, Dr. Rosen was particularly interested in hearing from our students about their impressions of Israel's health care delivery system.  Wanting to hear from our students was so gratifying to me as I listened to what they shared with some of the leading figures in health services research in Israel.


Leaving the Brookdale Institute, we had come to the end of our formal academic segment of the trip. One more day on Friday and then it is time to depart.