Healthcare Part One

ours offers some significant cost-savings, with the purchase of supplies, and

technology as well,” says Stephen Royal, CEO of Southwest Florida Regional

Medical Center, who also heads up HCA’s Southwest Florida region. “It’s

actually an advantage, having that type of corporate resources available,” but

any cooperative-buying among organizations offers the same benefit.

On the clinical side, “the early steps were simply working

harder — start the day earlier, stay later,” says Dr. C.B. Rebsamen, chief

medical officer of strategic services for Lee Memorial Healthcare System. “More

recently, as those kinds of options were exhausted, the focus has been on

process change,” becoming more efficient in scheduling and paperwork, making

better use of “eyeball-to-eyeball time,” and using non-clinical staff for more

tasks.

The Cleveland Clinic has found an internal, electronic

cost-accounting system helpful in controlling costs. It helps ensure

efficiency, cost-effectiveness, and that they’re doing the best they can with

those resources, Moon says.

“We’re trying to find new economies that we probably

wouldn’t have looked for if we hadn’t had the economic pressure. Sometimes

those economic pressures are healthy,” Nathan says.

But the benefits have their limits when additional pressures

are bearing down. “The public is becoming more discerning,” Morton says. “We’re

dealing with more discretion on the part of the public and I think that’s very

appropriate. But at the same time, many of the people who consume healthcare

are not directly — certainly as taxpayers, but not directly — associated with

the cost of healthcare, such as the Medicare program. That somewhat isolates or

insulates, in our case, 60 to 70 percent of the business from some of the

consequences that potentially — if this Balanced Budget Act matter is not

addressed — will result in medicine that is not as good as it could have been.

“When one is reimbursed based on rates that were derived

five years ago and have not, in fact, increased but have decreased, one can’t

afford new technology, one can’t afford new drugs, one can’t afford to pay

competitive wages.”

Labor Problems

In a tight labor market, compounded by a nationwide nursing

shortage, competitive wages are crucial.

The local unemployment rate is even lower than the national

average, and “whereas, in the past, we might have competed with another health

system and maybe even a grocery store for labor, now we compete against

Walmart, McDonald’s. We’re competing against everybody,” says Wiest. “It’s just

supply and demand and when it gets out of kilter, the price goes up, and that’s

what’s happening.”

The problem is exacerbated by Southwest Florida’s seasonal

market. During the winter months, some physicians’ offices turn away patients,

others have policies that they won’t take seasonal patients, says Williams, of

the Collier County Medical Society. Some practices — especially among primary

care physicians — schedule appointments for only a small portion of the

workday, leaving the majority open for unscheduled calls and visits.

In hospitals, seasonality poses significant staffing

challenges.

“You can’t just add and delete people that fast. It’s not a

construction business where you can just say ‘Well, we don’t have enough work

for people today’ and send them home, because of the high technology and

training that’s necessary,” says Jim Nathan.

During the winter, the healthcare industry becomes more

reliant on temporary workers and on “travelers,” nurses and other skilled

workers who move with the snowbirds from northern resort areas.

The influx of tourists and seasonal residents also takes a

toll on hospitals’ budgets. When people need care — even for minor ailments —

and they don’t have physicians locally, they head for the emergency room. Not

only is that by far the costliest option, it puts a crunch on the staff and on

Emergency Medical Service units. If EMS needs to get a cardiac patient into an

emergency room that’s backed up with flu cases, everyone is affected. In some

cases, the EMS unit is diverted to the next closest emergency room, so it ends

up affecting other hospitals, as well.

“At least one third to one half of the patients in the

emergency room could be treated in doctors’ offices,” Rebsamen says. Lee has

tried to alleviate that problem by establishing a “fast-track” program in its

ER, with nurse practitioners treating the milder cases.

The problem remains, though, and attention is being focused

on finding more relief measures.

The Technology Trap

In coming years, the approach to healthcare may take a

sharply different tack, say Wiest and Rebsamen.

Imagine going into your doctor’s office, having a swab taken

from the inside of your cheek and being able to tell how likely it is that

you’ll get colon cancer. An 18-year-old could find out his risk, at age 50, of

prostate cancer. The human genome project and genetic mapping research could

allow that kind of breakthrough within five or 10 years, Rebsamen says.

“Those are going to be very, very exciting break-throughs

for the medical community,” Wiest says. I think we’ll finally shift a little

bit and really get out of the repair-shop mentality and start to move toward a

preventative type of mentality.”

Medical advances offer exciting possibilities and new

technology and pharmaceuticals become available almost daily, but at this point

they also pose problems because of the cost involved. Federal reimbursements

and insurance companies lag behind the developments, so hospitals and

physicians often cannot afford them.

“Let’s say a new medication comes out that’s the right thing

to give a heart patient, but it’s not reimbursed,” Nathan says. “But it’s the

right thing to give, so what are you going to do? You have to give it. ... But

we might not be reimbursed for it, so that creates a really significant

challenge for us.

“The cost of pharmaceuticals has been increasing in the 15

percent range for the past few years. Meantime, the reimbursements for hospital

services have been either on hold or on a decline.”

Growth Issues

The situation might look grim, but while hospitals are

closing and going bankrupt throughout the country, facilities in Southwest

Florida are looking for ways to grow.

“A lot of the traditional, major, what I call ‘medical

meccas’ that we grew up revering in other parts of the country are in even

greater challenges today,” Nathan says. “Most teaching hospitals in

Pennsylvania are either bankrupt or close to it, and many of the major, very

well-known facilities in the Boston area are in serious dire straits.”

By contrast, Southwest Florida’s healthcare systems are

struggling to meet existing needs at the same time they’re facing pressures to

expand to meet the demands of a growing population.

“We’ve had a 28 percent increase in overall admissions to

Lee Memorial in the last four years,” Nathan says. Some of that is because of

shifts from HCA hospitals, largely due to renegotiated contracts, but much of

it is simply a matter of population growth.

The NCH-Lee Memorial partnership is answering that in the

Bonita area with the new community health center, and NCH has several other

projects in the works, as well.

Cleveland Clinic Florida is building in Naples in response

to demand, Moon says. “A considerable number of patients were coming to us from

Southwest Florida to the Ft. Lauderdale facility.” That facility will help fill

an existing gap, but it’s not the only answer. “There probably is an unmet need

and I think the demand will continue to grow.”

Which Way to Turn?

The answer lies, in large part, with Congress, say the

healthcare leaders.

“We’ll have to see if Congress lets its people go here, and

frees itself from constant partisan bickering and begins to address the needs

of its citizens as opposed to its own needs,” says Morton.

To Rebsamen, the answer lies in a meeting of the minds among

the three components to the healthcare system: the providers, the consumers,

and those who pay — meaning not just the insurance companies, but employers,

who pay many of the insurance costs, as well as the federal government.

“I think the managed care era in the last 15 to 20 years is

being questioned in terms of ‘Is this really creating the type of healthcare

that America really wants?’ I think we’re getting ready to enter a new era,” he

says. “The individual is beginning to sense that they’ve got a lot fewer

choices, they’ve got less control over their healthcare decisions, they’ve got

a lot less time with their doctor. They don’t like that. ... We’re going to see

a lot of debate about how we’re going to do this, how we’re going to give

people the kind of personal level of care that they’re looking for, in a way

that isn’t so inflationary in the cost that society can’t afford it.”

Jill Tyrer is a freelance writer and editor based in Cape

Coral.