I recently had the pleasure of attending the HealthLeaders CEO Exchange to discuss topics facing today’s healthcare executives. Throughout the event, attendees shared thoughts, concerns, and success strategies around a variety of topics. Specifically, the summit fostered meaningful conversation around strategies to manage declining reimbursement and increasing cost and demand for services.

What I found most interesting was how the emerging themes were not strictly related to the types of insurance programs and government participation incentives, but instead provided themes that were more in the vein of ethics and philosophy. With attendees asking tough questions such as “What is the right thing to do for patients?” and “What responsibility does the hospital truly bear?”, I wondered how leaders across the country are thinking about these questions and what their answers might be.

What is the “right thing” to do?

I have found that most people who work in healthcare choose this field because they truly care about patients and making their communities healthier; however, the day-to-day bureaucracy and intense clinical situations that occur within the hospital and other care settings make it easy to lose sight of this guiding principle. Many questions posed by the executives explored the challenges surrounding doing what is right vs. what will keep the lights on.

One discussion that sticks out is around the needs of rural patients and how their care may differ if their hospital is or is not affiliated with an Accountable Care Organizations (ACO). The CEO of a hospital that does not participate in an ACO made a strong case that without charging for additional “widgets”, the hospital cannot remain viable and provide care to that rural community. In this scenario, reimbursements were higher with readmissions and more tests completed.

Another CEO countered that regardless of ACO participation, the “right” thing for patients is the reduction of unnecessary testing that can be risky and costly; as such, timely alternative care delivery models are necessary. These can include devices in the home and telemedicine consults.

It is possible that these new models of care delivery may reduce episode of care cost, while still delivering quality and ensuring safe and effective transitions beyond the inpatient setting. While it may be necessary for the hospital or insurance plan to pay for these services, it is still less costly then readmissions – and more importantly, prevents patients from suffering undue harm. What the conversation re-affirmed was the need to quickly and effectively move from fee-for-service models of care to those that measure and evaluate value, outcomes delivered, and care that is more coordinated and leaves the patient happier and healthier.

Integrating Social Determinants of Health into Care Delivery

Social determinants of health (SDOH) have long been a topic of conversation; however, in the past, this has been mostly driven by health plans. As hospitals and other care providers look to capitalize on value-based payments, SDOH is becoming more top-of-mind.

Traditional inpatient care stopped at the point of discharge, but research supports that patients with high-risk diagnoses may do very well because of strong support systems in the home. The absence of issues, as noted below, allows them time to heal and/or manage their condition by following prescribed treatment regimens. Conversely, a patient considered “low-risk” may swiftly deteriorate and end up readmitted because of the presence of social determinants that negatively impact their ability to heal and manage their own care.

Social determinants of health that may have a significant impact on outcomes include:

• Lack of caregiver support systems in the home – live alone or family/significant others are unable to provide appropriate care
• Catastrophic issues in the home – drug addiction, death of a loved one, violence
• Patient has responsibility for care of others after discharge and cannot care for self
• Financial crisis or homelessness

One of the summit attendees, a passionate physician and CEO, summed up the very essence of the discussion with a patient story. A man came to the Emergency Department with a severe sore throat and fever. He was dehydrated and lethargic. After receiving intravenous fluids and an initial antibiotic for strep throat, he was discharged feeling stronger and with a prescription for a full antibiotic regimen. That patient returned to the ED days later in septic shock. He was admitted to the ICU and quickly deteriorated. Sepsis in the ICU has very high mortality despite high-cost interventions and long length of stay. It was later learned that the patient did not get his prescription filled and did not take the antibiotics as prescribed because he had limited financial and personal resources. This patient had many of the poor SDOH listed above; had they been addressed prior to or immediately after discharge, his outcome may have been much better.

Although stories like this are hard to read, it is important that we discuss them and systemize value across the care continuum to do “what is right” for the patient. One thing is certain – healthcare has expanded beyond the four walls of the hospital. Regardless of reimbursement model, care providers face increasing responsibility for communication with patients after discharge. The methods of communication can take multiple forms, but it must occur. Something as simple as identifying a risky social determinant, which would have otherwise prevented a patient from following their plan of care, can avert a catastrophic readmission to the ICU – catastrophic because the hospital must shoulder the burden of the staggeringly-high cost of readmitted care, but more importantly, the devastating outcome for the patient.