OPINION – March 16, 2013 -- I have often thought that breaking down the silos that exist in our healthcare system is an important step in transforming our fee-for-service healthcare system into one where we pay for health, quality, and cost-effectiveness. My thoughts about silos have focused on clinicians' reluctance to adapt to electronic health records (EHRs), hospitals purchasing physician practices (e.g., we must own them) and not properly incentivizing them, and health information technology vendors insisting on their form of contracts, and contending they are the platform, rather than facilitating interoperability.
Further thoughts of silos have been nurses concerned that their roles might be diminished if they do not take the lead on patient-centered medical homes, physicians fear of losing what little autonomy they might have, hospitals having to cede power to physicians, and health plans upset that they cannot be Medicare Accountable Care Organizations unless they own a provider component of the healthcare delivery system. Also, some health plans fear that they may lose their market position/importance if providers take a lead in the transformation. Then, there are many of the ancillary healthcare companies, laboratories, pharmaceutical companies, medical device companies, etc. who might fear that with the transformation, they are becoming further detached from the sources of revenue.
We also cannot leave the lawyers and consultants out of this discussion. Many attorneys and consultants approach change as a way to apply their current skills, but not in the context of problem solving. That is, merger and acquisition (M&A) lawyers view the transformation in healthcare as a means to do more M&A work. Lawyers specializing in regulatory issues, such as fraud and abuse and antitrust, often see the changes in the system through the lens of a regulatory lawyer, e.g., an opportunity to locate the regulatory considerations, on which they might work. Similarly, consultants, such as valuation consultants, view the transformation as an opportunity to do more valuations, and revenue cycle consultants might consider all the new revenue cycle consulting opportunities with more individuals being covered by a form of healthcare insurance.
The above are the known motivations that might be obvious hurdles to fully implementing the steps necessary for the transition from fee-for-service healthcare to payments for health, quality, and cost-effectiveness. However, there are many many more hurdles which are not apparent to those who are not involved in the details of our healthcare delivery system.
A few weeks ago, I had the pleasure of sitting next to a woman on a flight to Portland who works with a company that markets a device that makes patient information available within moments to the providers in an Emergency Department of a hospital. The standard time for this information, given what the hospital laboratory might do, was apparently a few hours. She said one of the biggest hurdles she experienced was the push back from laboratories in the use of the device. She thought that the hospital laboratories were trying to protect their turf.
I immediately thought, this is a silo that I had never even considered, and how many more might be out there. It reminded me of the time I was playing golf with some other attorneys on Coronado Island, when there we no cell phones, only pagers. One of the in-house counsel in my group was paged. Apparently, his hospital had discovered that one of the physicians on staff was not properly licensed. He put one of our foursomes golf clubs on the other cart, hopped into his cart, and to the question one of the other members of our group posed, why are you running off, you already know about this physician, the situation is contained. I replied, the point is that is exactly what everyone else thinks. He is going to work on finding out how many other clinicians are not properly licensed on the medical staff of the hospital. Of course, this is why he left the course on a gorgeous day. He subsequently discovered that there were more physicians who should not have been admitted to the medical staff but they were on it.
So….when I think about the instance that the medical device person related to me, I immediately thought about what are the other many silos that exist in healthcare, that are impediments to the delivery of quality care in a cost-effective manner. I must confess I do not know. I am sure no one knows even where all these silos might be. However, how can we fully implement the transition from fee-for-service medicine to paying for quality and cost-effectiveness without identifying and breaking down these silos? How can we provide healthcare to the 40 million or so new folks who are expecting healthcare, unless we become more efficient and cost-effective? How can we implement the Coordinated Care Organizations (CCOs) in Oregon that we so desperately need to implement?
The other day I heard a presentation about "lean," a concept that does include breaking down silos, involving employees in focusing on inefficient areas, and developing better practices. I could not help thinking during the entire presentation, how could the healthcare industry have possibly gotten itself so far off track that it would need to even think about lean. These concepts should be so woven into our everyday lives in healthcare, that we should not have all this work in front of us. We only should have to make these strides on the margins, but alas, we do need lean, and better practices. In fact, we need employees in the healthcare industry to help ferret out the problematic areas and to be change agents in fixing them. We need all of us, whether we are employed by a healthcare entity or a consumer of healthcare, to be involved and be change agents.
When I was a small boy, I used to wonder why my father, who was in the restaurant turnaround business, got to know all the employees names and many of the names of their family members at the restaurant, why he listened to them so attentively, why he always tried new things, better practices. One day he told me that although there were many things similar about restaurants, everyone was different, and the employees knew many of the things that would turn around the business. It was a matter of having them share with him what they thought needed to happen. From his years of experience and listening, he was able to change the course of a number of restaurants. I know when I worked in the hospital turnaround world, we got to know the employees and we listened.
If we are going to transform our healthcare system, we have to do it one step at a time. We have to listen to our healthcare workers and patients. We have to assist them in becoming change agents. We have to start one employee and patient at a time, and we cannot put this process off any further. The viability of our healthcare system is at stake, along with the health of the people in our country. It is a herculean task, but one we have to be up for. We cannot continue to perpetuate the silos we have today. We need to break down healthcare’s silos.
Paul R. DeMuro JD, CPA, MBA, MBI, Schwabe, Williamson & Wyatt, PC, National Library of Medicine, Post-Doctoral Fellow in the Ph.D. Program with Oregon Health & Science University.
