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Many of our systemic health care delivery system ills cannot be cured by legislation. The real revolution will come to health care when we reach a culture of wellness and prevention, says John Bluford, president and CEO of Truman Medical Centers, Kansas City, Mo., and the new chair-elect of the American Hospital Association.

Health care service is a family affair for me. I had many uncles in health care and my grandfather was a dentist. I went to Fisk University in Nashville majoring in pre-med and I was on my way to Meharry Medical School when a recruiter for Northwestern University's business program interviewed me. The gentleman tried to convince me that I ought to go into business because of my orientation toward extracurricular activities and leadership roles with my fraternity, student government and the basketball team at Fisk. I told him I knew nothing about business administration, but I passed the graduate school test and received a full two-year scholarship at Northwestern sponsored by what was then the United Insurance Company in Chicago, plus a $250 monthly stipend. In 1971, that was good spending money. So I enrolled in the business school with a hospital and health services major. The real hook was when I realized that you don't have to be a doctor to work in a hospital. You can lead a variety of activities that help support many doctors and their patients in an administrative role.

My first job in graduate school was at the 3,000-bed Cook County Hospital. As an administrative resident, I was the weekend administrator under Bill Silverman and Bob Shakno, both of whom came from Michael Reese Medical Center to help turn around Cook County Hospital in the early '70s. This was a very turbulent time at that county hospital, following much-publicized strikes by residents and nurses. After graduating from Northwestern, I took over as the night administrator. It was training under fire, but the beauty of it for me was that on weekends and nights, I had overall administrative responsibility for the hospital.

I have many stories after being the night administrator at Cook County. My favorite is the night I was looking at the surveillance television monitor and saw one of our buildings on fire. About 16 buildings comprised the Cook County campus and the psych hospital was on fire. I had Bob Shakno's home phone number. He always said, "If there are any problems, just call me." Well tonight was the night. His response: "Step No. 1: Call the fire department."

Today's Non-System

The business we're in today is very complex and often contradictory. We're rewarded for sickness but not wellness and prevention. So many component parts create this non-system—insurers, physicians, hospitals, pharma, device manufacturers—and each component part represents a competing interest that resists change. The cost of health care is a big issue and we all want to reduce cost. But someone's cost is someone else's revenue. Therein lies the root of many of the health care reform political battles inherent in moving the system forward. That is why I am so pleased with AHA's Health for Life platform (coverage, wellness, efficiency, highest quality and best information) as it takes a comprehensive look at the total system(s) for reform.

Today, many uninsured people lack access to appropriate care, at the appropriate time and the appropriate place. One way of thinking is that sick people don't need insurance; what they need is appropriate access to health care. Today, they often access health care through safety-net hospitals and emergency departments, where ongoing continuity of care may suffer. Appropriate health care reform, which increases appropriate access to services, may not be cheaper in the short run, but we might have a healthier society and other benefits to the common good.

The long-term key to success is the prevention of illness and managing the costs associated with sickness. A rallying cry around the country in support of lifestyle enhancement, physical fitness and good nutrition would be the biggest enhancement to health care reform that we could achieve from a quality-of-life perspective.

End-of-life care counseling can also have long-term results. Evidence already exists that a 90-year-old with multiple system failure can either stay in a highly intensified, technological ICU environment and have dozens, if not hundreds, of tests done by high-profile professionals for weeks or that person can go home and be treated with dignity and surrounded by loved ones. The irony is that the length of life is the same in either situation. But the choice for quality of life is a no-brainer. We are often incentivized to do more expensive yet less effective modalities. Unfortunately, end-of-life care issues were avoided in the current reform legislation, but eventually the collective American community must discuss it.

Societal Disparities

My 30-plus years in health care have been in the public or safety-net hospital environments that, on the whole, cater to a vulnerable patient population with a high degree of health care disparity. Their condition often represents social disparities—not just health care disparities. Ethnic and racial disparities come into play as well; but broadly speaking it encompasses the people with fewer employment opportunities, sometimes with poor family support, inadequate housing, and this aggregate population crosses all racial and ethnic boundaries. Much of the reform debate in terms of access and cost is really about this vulnerable patient population. If we focused our attention here and society provided resources to solve the underlying problems, we could carry health care reform further than any legislation.

The focus on continuity of care, medical home experiments and advocacy issues play neatly into helping us get our arms around the problem. Many of our clientele have chronic diseases that are not managed well, and they don't have system navigators to get patients from point A to point B to make sure they keep their appointments, manage medications, and so on. And in many cases, the people who treat them can't associate or identify with them to the extent that it takes to overcome or break through the social disparity aspects of their lives.

Research comes into play, but so does common sense. I get frustrated with "process" versus common sense and the prompt execution of good ideas. There sometimes needs to be a greater sense of urgency and balance between research, process and action. If we know that asthma is a problem for a pediatric patient who repeatedly comes to the emergency room, then someone needs to go to the home and find out what's going on in that environment that is creating the problem.

We are about to start a program at Truman Medical Centers that we call Passport to Wellness, which is targeted at our "frequent flyers"—those people who are constantly readmitted, who make a dozen or more visits a month to our emergency room, and have chronic diseases such as diabetes, hypertension, asthma, chronic heart failure. We want to identify about 100 of these patients and provide as much intense case management attention as possible to see if we can solve their issues.

Sometimes we need to think about different types of interventions in dealing with vulnerable patient populations. I was talking with the head of our EMS system about Passport to Wellness and he said, "I see some of these patients 20 to 25 times a month. Many are diabetic and they need medications and some basic assessment. They call us because they know that if they come in by ambulance they will come through the emergency entrance and won't have to wait two or three hours in the waiting room." Bingo. Why not use these talented, skilled emergency medicine service workers? They are at the house, they can administer the medicine, and in many cases they know the patient better than the rest of the health care system. Perversely, we would lose Medicare payment for a full run to the hospital, but the economical, simple thing to do may be to let the EMS workers meet the needs of the patient on the spot.

The whole mental health sector needs to be brought into play as well. A great proportion of the vulnerable patient population has either mental health or addictive behavioral problems. Also, many people who are incarcerated should probably be in a mental health institution, as should many of our homeless. Our society has not opened our eyes to those realities yet.

All of the significant mental health, psychological-related issues and clinical issues associated with behavioral health are upon us. It is a slightly different business than running an acute care hospital. It is often not a money-making proposition. The capacity is woefully low. But it needs to be addressed.

Safety-net hospitals are critical to the communities they serve, not just because they tend to serve the vulnerable and disadvantaged population; safety nets are not merely for the downtrodden. Safety-net hospitals provide services such as Level 1 trauma units, high-risk neonatal units, burn units, oral health, and teaching and training programs that are vitally important to the entire community and may not be available in other parts of that community's delivery system.

They are also major business entities. We hire a lot of people. Safety nets pay lots of payroll tax and contribute significantly to the local economy through the acquisition of supplies, commodities, construction projects and so on. And because most safety-net hospitals are in the urban core, it is even more critical that they continue to be one of the major engines fueling that inner-city economy.

The maintenance and survival of these institutions is an economic issue as much as it is a health care issue.

Unintended Consequences

There is no question that there will be unintended consequences all over the map as the reform process runs its course over many years. It took more than a generation for us to get into our current circumstance in regards to cost, value and quality, and it is going to take some time for us to find our way out. Whatever happens with health care reform legislation today, it will be constantly modified over the next 10 years until we have a system that is more resourceful and meets more needs than the system does today, at a reasonable and affordable cost.

A theme in this year's discussions is that hospital environments with employed physicians, such as Mayo and the Cleveland Clinic, have better continuity of care, better results and run more efficiently and effectively. The physicians and the hospital are not working at cross purposes with cross incentives. In most institutions, the hospital and the physicians are legally independent organizations, but they are connected at the hip financially; one can't move successfully without the other. The new world order through health care reform with strong disease management, bundled payments and gainsharing arrangements should lead us in more unified alignment.

There are two things that create problems for chief executive officers. One is ineffective relationships with physicians and the other involves poor decisions or implementation of major IT projects. Today, the electronic health record is top of mind. And it will benefit the system, patients and clinicians, but it is not the silver bullet. Migrating from paper records to electronic documentation is very difficult and expensive. Without a thorough operational audit of user requirements and fixing the problems in the manual process before automating simply means that you get bad processes faster.

Another element that is critical to hospitals' long-term success is high-performance governance. Qualified trustees who are engaged and buy into the mission of the institution will advocate for that mission throughout the community at large. One of management's responsibilities with the board is not merely answering the questions that they ask as truthfully and honestly as you can but also, in some cases, showing them what questions to ask because often they don't know. That kind of openness and transparency in governance makes for a much stronger institution and across the nation will lead to a much stronger health care delivery system.

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