Ayman El Tarabishy: I’m delighted to be here with Dr. Howard and let me introduce him and I’m going to read this here from the script because it is very impressive. So, Dr. Howard is a Director of Healthcare Program and the Director of Research for the program and physical therapy at the George Washington University. Formally he was a Vice President of the practice and education for the American Physical Therapy Association, where he oversaw association efforts and activities designed to improve and enhance the state of physical therapy education and practice.
Dr. Howard also holds an academic side and he had academic positions at Columbia University, New York University and Sunny Healthcare Centre at Brooklyn. Dr. Howard earned his BS in physical therapy from the state university of New York at Downstate Medical Centre and his MS and PHD degrees from New York University Biomechanics and Ergonomics program.
He has published and presented nationally and internationally in the area of physical therapy, occupational health, low back pain care and prevention handing and movement, healthcare policy and quality and leadership. Very impressive and very broad but at the same time very specific, you’ve taken both global and local, so I call it glocal.
Kenneth Harwood: I guess so, right okay. [laughs]
Ayman El Tarabishy: What I’d like to do is get into some of the questions that we, that I wrote here in collaboration with you and let’s get to the point right away.
Kenneth Harwood: Okay, great.
Ayman El Tarabishy: So let me start with the first question here, we here that patient centred care is a foundation to the new models of healthcare. So, patient centered care is the foundation of the new models for healthcare. Can you explain what patient centred care is and how it is different from present models of healthcare?
Kenneth Harwood: Sure. One of the, probably one of the biggest changes that we’re seeing with healthcare reform and new models of care is that there’s an attempt to try to make it rather than on the if you will convenience of the healthcare provider or the healthcare system much more on the convenience of the individual patient themselves. Especially now that we actually start to see the complexities associated with good healthcare, especially value based healthcare for individuals throughout the United States. And certainly we can globalize this but we’ll just stick to the conversation that we’re having in the United States.
So, therefore when we actually start to look at a system that really values the care, and what I mean by value is actually not only looking at what is provided to the patient but what is actually needed for the patient and what the patient wants. We started actually delve into a little bit more what we mean by value. And I’ll just side track so value at this case is looking at really the patient outcomes, that is what the patient wanted and how close they got to what they wanted to the course that we actually used to get that care.So, as we started to generate new evidence and literature we actually found that we were missing the mark, most of the systems now are something called more volume based care, which means that the more you give, the more you get paid, never really taking the patients as being the center of something that actually needs to happen to be changed, whether it be a new surgical procedure and/or a new lifestyle or even things like a new diet or a social program that they actually require.
So, when we look at patient centered care we’re really looking at changing the focus, the focus will no longer be the focus of the physician or the healthcare provider but really looking at the focus of the patient. What are the needs of that patient? And we’ll talk a little bit more about this, especially the special needs of chronic care management but we’re really changing that focus on what are really the need, wants, desires of that patient?
And that’s a fairly tall order when we look at it today ’cause in general as an example, let’s imagine I’m a patient and I’m wanting to manoeuvre the healthcare system today, in general my convenience is never really taken into consideration, who I need to see, when I need to see them. Patient centered care will actually start to look at that. How do we actually generate good care that is value based that allows the patient to be the center. And it sounds like a good thing to happen, meaning that people – it’s almost a desire for everyone to have the patient at center.
But actually to implement it in a very complex healthcare system that we have is not very easy ’cause it’s the idea of actually how do we actually gain access for every patient that allows them to care that they need at a course that’s effective and efficient. And I think that’s really where we actually are seeing where innovation is happening now. It’s that idea of how do we make something patient centered but also cost effective and actually looking at the outcome of that patient, outcome at the end.
There are an amazing amount of innovative practice models that are going on now that actually are able to achieve that. And therefore, especially for me as a health services researcher, I’m so interested in this area ’cause it actually means that we are getting to really kind of a win/win for everybody, the patient, the provider and hopefully the healthcare system.
Ayman El Tarabishy: So, let me delve a little deeper in this and talk about chronic disease change in healthcare.
Kenneth Harwood: Okay, good.
Ayman El Tarabishy: Tell me a little about it. What are the implications for this for the whole healthcare enterprise?
Kenneth Harwood: Okay, great. And I think that’s actually probably one of the most important questions that we’re dealing with now mainly because just some statistics right now in the Medicare population. About two thirds of individuals in the system right now have at least two chronic conditions. A third of those individuals actually have four or more chronic conditions.
So, it’s not something again it would be nice to happen, we actually in reality have to deal with this problem ’cause it really is the reason why we’re spending close to 17% of the gross national, domestic product on healthcare is because many of these individuals actually are the high spenders, that is the high consumers of healthcare.
So, there’s an estimation we always use in lower back pain and actually have been using this statistic ever since I started in my field in physical therapy and in research. About 80% of the population who actually get something like low back pain just become, they go on in their life fairly easily. They have the episode, the move on and they actually do very well.
20%, again statistics will change, 20 to 30% of those individuals actually go on to a chronic nature, meaning it takes longer for them to get better. And there’s a very complex association between when someone actually has what we call acute care that is the episode that they have a couple of days that they’re injured and then they actually go back to work slowly and then they finally go back and they’re absolutely fine. It’s those 20% of the people that eat 80% of the cost.
Kenneth Harwood: Exactly. So, we can debate the 70/30, 80/20 rule. But so therefore when it really comes down to it if we’re going to affect change in something like low back pain for in this case is actually more of a model for chronicity, and we can go to different other models like obesity and Diabetes etc. but we’ll just stay with low back pain. We actually find that as we actually start to address that 20% of the population we’re seeing its most effect on the costs associated with care.
So, as we start to look at chronic care management, that is really making sure that we’re taking care of those individuals who need our services, ’cause in some cases the other 80% really don’t need healthcare services, they’ll get better on their own. It’s those individuals who we have to take care of.
And actually we just completed a study and looked at more new models and what we did was we looked at claims data for low back pain patients, about 180,000 claims we looked at. And at that point when we saw the type of care that we found, and again it’s a little self promotional as a therapist, but we definitely found that if physical therapy were the first contact, not physicians but physical therapy, there was a decrease in emergency room visits, there was a significant decrease in opioid use, which is a major issue that we’re dealing with in the United States right now. And also major decrease in course associated things like MRIs and CAT Scans, which we know at this point aren’t necessary for most lower back pain patients.
So, as we really start to switch our focus from what most people think of healthcare, which is basically I injured myself, I go to a physician, I get a medication or a surgical procedure or something and then I go back to my life. Our focus now is those individuals, those costs associated with aren’t so much, they’re pretty direct and straightforward. It’s the chronic care individuals, the ones that take the 80% of the cost that really should be our focus.
And actually that’s what most of us are looking at right now, how do we change the behaviours of individuals who actually have things like Diabetes. How do we actually change that? Because if unchanged, they become huge, if you will, users of healthcare, so it’s this change in healthcare, change in focus in the healthcare dollar from what we considered, I considered the traditional medical model to a more complex bio psycho social model.
Ayman El Tarabishy: So let’s dig deeper now, let’s have this conversation. You kept using the word patient. And patient I agree with you, they’re patients, but in the business world they’re customers.
Kenneth Harwood: Okay.
Ayman El Tarabishy: So let’s talk from a customer perspective.
Kenneth Harwood: Okay that’s a great perspective.
Ayman El Tarabishy: Alright so if we’re using the 20/80 rule and you mentioned 180,000 claims.
Kenneth Harwood: Of the claims.
Ayman El Tarabishy: Of the claims, 180,000. So there are 180,000 potential customers. If you move them away from going to the doctors and going to physical therapy you’re basically saying to the doctors you’re losing business. How do we balance this out? Because at the end the physician that’s running their own clinic or is looking for a capacity or a demand because I know I keep using the bad word customers but this is the business world. If we’re shifting the model we’re taking away 180,000 potential customers from them. How do you react to this?
Kenneth Harwood: Well, I think it’s real life. I mean it’s been my life as a clinician that that basically had been a focus. It depends upon really where you’re emphasis is going to lie. If we do a healthcare system that’s driven primarily and only on a system of consumerism, that basically is I have a service you want this service, I can have that service and I can have anything that I want, which is somewhat what we had, a fee for service payment model. Basically what happened is we started to go into not only inappropriate care but fraud and abuse. We also went into areas where actually the costs associated with care ballooned over very short periods of time.
When actually we went back and we looked at the evidence associated to the actual care that is best for that individual., we found that actually that’s not the best model. The best model actually looks toward actually – let’s say with lower back pain or I can take it to another area if that’s more comfortable for you. But if it’s actually looking at low back pain, we know in essence surgical procedures almost always not indicated. What really is indicated is getting back to your life as quickly as you can.
So, therefore the model that we’ve used, the archaic model that we’ve used in the past with low back pain was really just preventing that individual to really understand that for most cases low back pain actually is fairly innocuous, you actually will get better. And in fact there are studies that actually show that when a physician or anybody shared that to the person they did get better ’cause actually they understood that okay, I will get better.
Now let’s take the other end of that. The other end of that is actually okay so the consumer or the customer actually should be informed about this information. This way they’re making a well defined choice. I think at this point out system right now doesn’t provide that type of information to the consumer. We want a well educated consumer, especially in healthcare. We want them to understand the implications of the decisions that they made. And even more importantly, the decisions that they don’t make, that are made for them.
So, I think at this point even when you take a very clear business model with this discussion, the outcome I think is about the same, that basically what you want is the consumer to understand not only the system that they’re under but also the problems that they have. And therefore to make good informed decisions.
So, therefore if in fact we were only to look at the perspective of the physician that actually would be losing customers, I would say then you know what? The business of healthcare is actually more than just a consumerism aspect. There is actually clear understanding of what is better care and what is not so good care and therefore there is a high level discussion that needs to happen beyond a dollar discussion.
Ayman El Tarabishy: So how, again I’m putting my hat on as physician, how would I react to this knowing that I’m a partner in a clinic or with three or four different doctors and we’re realizing this and we agree, the mission is absolutely – I agree with you. Should we then explore opening a physical therapy as an added service to our clinic?
Kenneth Harwood: Well partnerships with other therapy sure. But I think at this point now I think we move into a whole new area of really a team approach to care. And I think that’s really what’s going on now; it’s that idea that understanding that actually in some cases the team needs to be different, depending on the individual types of care.
So, Michael Porter I think described this very well in the IPU or the integrated practice units, which basically says it really shouldn’t be up to the physicians or healthcare providers on what care needs to happen. It really should be based on what’s the outcome, what’s the best outcome for that individual, for the dollar that we spend? So, most cases when it comes down to these very complex, chronic care issues, it actually takes much more than just a physician input, there needs to be an input from multiple providers, so, therefore if you were a physician and looking at business models, certainly unique partnerships are actually a good way of going.
Ayman El Tarabishy: So we’re at a table right here. We’re negotiating here, I’m the business person, you’re the physician and we’re running this business, [potentially] running this business. Who’s in charge at the end? Even though it’s supposed to be a team approach, who drives the decision? My opinion it’s the patient’s care that comes number one. So, there needs to be a balance. How do we strike that balance? That’s the trick, that’s the $60,000 question.
Kenneth Harwood: Right, I agree. But it hasn’t been, let’s be honest. Up until now it’s been a volume based decision, I mean value based system where actually as a physician I just build more I got more regardless of really what the positive care is. If we focus on the patient, which is how we started this conversation, basically our focus becomes somewhat different. So, what is best for that individual to get better? Why don’t we go back to the literature? What does the evidence say that they need to do? How can we make this more effective and efficient?
So, I think really when it comes down to business models, as a business person myself when I was in private practice, it became the issue of not maybe increasing my productivity as in number of consumers. It was really looking at efficiencies and effectiveness, which basically and if you agree with Porter, to become specialized in a certain area may be important.
Ayman El Tarabishy: I’m going to read you a question that we talked about here. Recently there has been frequent and robust discussions on the quality of U.S healthcare system. What are the drivers for this great interest in quality of the healthcare system? I know you talked about it here but let’s get more into it.
Kenneth Harwood: Okay. So, I think when we look at just generic statistics about the United States system, I think it becomes, and this is pre healthcare reform data, although some of it is more updated now. We actually see that although we spend in some cases two to three the amount of money on healthcare in the United States we have poorer results when it comes down to the outcomes of the patients. An example is when we look at chronic care management, we actually are terrible with chronic care management as compared to other industrialized countries. We spend 17% of our gross domestic product on healthcare. No one is near close to that. When we look at the costs out of pocket for people who are receiving those services, we are in some cases two to three the amount of money in the United States that people are paying out of pocket to actually get the services that may not be as high quality to other places.
I actually – every year I teach in Singapore and one of the things about the great thing about Singapore they have a national system but then also, and I’m not being political here, but they have a national system but also they have a system that actually is ranked in most cases two to three, sometimes first, in the world. Small little independent country, how did they do that? And they did it really by systematically looking at the healthcare provision of care and made sure they were giving appropriate care to the appropriate person.
So, when it comes down to the driver of healthcare quality, I think the major drivers were really cost drivers, they actually we can’t continue the way we were going, we just couldn’t. The other issue is when we looked at those numbers, the dramatic numbers of costs that we were associated with, our outcomes were really bad as compared to the amount of money. You know, the great thing we all have in the United States is we have innovation, we have high technology, we have new products coming out every day. The problem is, and I read one statistic, the numbers of new patents per year outshine every other country throughout the world.
However to make that effective and efficient you actually have to go back to say what did the patient need? And I think in the United States we have to have that very hard conversation of what did the patients need? Sometimes they need something that they don’t want to have.
Ayman El Tarabishy: Baby boomers let’s talk about the baby boomers. I see this as a major challenge coming or is here. I mentioned earlier it’s a major challenge but I also see a major opportunity. Let’s talk about both, what challenges do you see and what opportunities do you see?
Kenneth Harwood: Well, we’ve certainly seen the aging of that population and everything that comes with aging, which is also associated to not only thinking things like acute heart attacks etc but also chronic nature of arthritis, especially the group that I belong to in the baby boomer generation, were those individuals who were that weekend warrior and as a physical therapist I saw them all the time, that they were constantly injuring themselves. They get to this age, they actually do have most likely some types of arthritic conditions. In fact that’s probably why we’re seeing so many things like total hip replacements, total knee replacements.
So, I’d certainly say when we look at the kind of trajectory of the baby boomer, we’re actually hitting just a horrendous amount of people entering a system that perhaps isn’t really ready for them and especially the needs that they have. And I think that’s again one of the drivers that we’re seeing for healthcare quality.
So, as we start to look at, you know, how do we treat this very large group that’s coming in and what are the services that they’re going to need in a very complex healthcare system and a complex life. We actually are going to rely on perhaps more innovative ways of using things like information technology and how do we actually start using those types of issues, community based care programs, self care programs, things that can actually be used by individuals to actually help themselves get better and not necessarily rely everything on a healthcare system that is unable to meet the demands that will be coming from them. So, I think when we look at the challenges, the challenges are quantity I think as well as the complexity of some of these very complex chronic conditions that are coming up and having to deal with.
But the innovation and the challenge, I mean the real opportunity I think is just equal if not better. I mean we do know what to do with some of these people. It becomes the business person to be able to put that in action. How do you actually do community based programs that look at exercise and diet and make it profitable and make it something – I actually know of people who actually – one individual who I met was a physical therapist in a small little community in Pennsylvania and she found out that her community was considered, if you will, the fattest community in Pennsylvania.
Rather than accepting that, she actually went out and developed a business model to say how can I take care of these individuals in a very well done, evidence based way and become profitable? And I think those things are not necessarily separate, I think those things can absolutely be married. It takes the business person partnership with the medicine, medical people, healthcare people that I think can really drive innovation.
Ayman El Tarabishy: So, we have this new course that we’re doing on healthcare and business.
Kenneth Harwood: Oh are you really? [laughs]
Ayman El Tarabishy: Yes, that’s why you’re here.
Kenneth Harwood: Oh that’s right.
Ayman El Tarabishy: And so, what advice or knowledge would you give to the business people? They’re sitting there probably taking some notes or just listening and drinking some coffee. What are the things that, ’cause you were an entrepreneur and you are a professor and you are in administration, you’ve done, you’ve combined all the worlds. What do you see as these business, potentially business minded people, that they need to be watching out for?
Kenneth Harwood: Yeah and just as a caveat, in our quality healthcare program, we generally have about half of clinicians, half of business people that actually are taking this course now. Most of them are administration, especially in hospital or healthcare systems. So, I actually deal with this on a daily basis and part of our capstone project is actually for them to develop a comprehensive change proposal, meaning take their own business, wherever they are and come up with strategies that actually changes that business.
It was a amazing of some of these ideas that came up and I certainly would say some of, probably the positive aspects of having these open collaborative partnerships between the healthcare professionals and the business people as they can take the strengths of both worlds. I think the risk taking, innovative habits of the business person can be married very well with the evidence based risk adverse healthcare provider. And I think when you actually see those coming together, so everything from really developing great business models within a healthcare system that really needs that. I mean we’re really, when you look at the waste that occurs in Canada to have somebody who actually has that eye.
And I think we have some really good examples is John Hopkins where they came back and they started looking at that. It’s not necessarily easy transition ’cause I think many healthcare providers don’t necessarily – are comfortable looking at innovative risk taking behaviours but when it works well it can really drive change.
I think again, I’ll stay within what I know ’cause I can tell the details, Virginia Mason, which is out in the west coast I think in Washington Oregon, actually looked at that, they actually found when they were looking at low back pain and they were trying to say what’s the best care, they actually found that this innovative model where actually – an IPU only on spine, they had a 24 hour phone service, they actually were able to provide services right away and what the services where. Physical therapy obviously was an important component to this, exercise, community based efficiently done. They actually found amazing drops in cost and increase in outcomes.
Those are the types of innovative projects that we need to be looking at. And hopefully at GW we can start changing that behaviour and maybe we can drive some of these changes and be known for these changes.
Ayman El Tarabishy: So we’re going to go personal here, tell me about your business that you started, it’s all about entrepreneurship, let’s talk about business.
Kenneth Harwood: So, again early in my career, it’s not unusual for physical therapists to actually go out on their own to develop a private practice, but I actually had my doctorate in ergonomics and biomechanics. And for those individuals, ergonomics may not – most people when they think of ergonomics they think of chairs. That’s not what I did, I didn’t design chairs.
But I felt we’re spending so much time and energy dealing with people who have already been injured, why don’t we spend a good amount of time on preventing it. So, most of the business entities that I worked in, through really contract work in New York City where I actually worked at the time, we actually worked with fortune 500 companies. We were going in to look at mostly heavy industry and trying to look at developing systems that actually would prevent injury. And that actually kind of followed me even to this day. I still am involved in looking something looking at injuries associated to healthcare workers.
You know, right now one of the unattended consequences of the obesity epidemic that’s occurring in the United States is when individuals go into hospitals and are obese and need to be transferred from one position to another or assisted with those transfers. Individuals actually have to help them do that. An example, probably the biggest example is nursing. And actually we’ve seen in some cases horrendous amount of injuries to nurses because of having to change and lift these individuals.
So, when I was back in my kind of entrepreneurial stage, this was what I was concentrating on, how do I actually contract in first of all heavy industry and then started to look at more things like nursing homes and places like that that actually have a lot of safe, a lot of lifting and injuries to lower back pain associated to the healthcare worker. And it just made logical sense. ‘Cause I actually used to be on the work comp board in New York and it became very clear when we would see these work comp numbers, workers compensation just in case. We just, it was so obvious that we were spending so much money on this that an entrepreneur could come in and say, you know what I could cut this in half or 15% change, give me 5% of it and we have a deal here.
Ayman El Tarabishy: And two part question, what research are you currently doing on your professorial hat and tell me a little bit about you, you’ve been here three, four years, tell me about your GW experience.
Kenneth Harwood: Okay so my research I have three funded projects right now. We just completed the direct access study, which is 180,000 claims assessment and came up with a very positive outcome about physical therapy being directly related to the care from the onset. In addition we’re also looking at just kind of primary research, which is safe patient handling.
A lot of the information hasn’t been systematically reviewed and we just got some funding to do a systematic review of the literature on healthcare injury and then patient outcomes when using equipment to actually assist them in the movement within hospitals.
And the third one actually is a funded project that I’m on through the centers of Medicare and Medicaid, which actually is looking at a whole other community which is those individuals who are community based, long term care. Those individuals with severe mental illness that are aged, that are intellectually disabled and needing assistance and we’re developing a system that is trying to measure the function of those individuals to determine who much service they need.
Medicare actually is trying to make this systematic at all levels of what we call post acute care, that is after someone leaves a hospital, whether they go to home, whether they go to a nursing home, whether they go to a rehab institution or community based system. What we don’t have is a systematic way of assessing these individuals to determine what is the best care for them. We’re working on a project looking at it now to see, can we systematically assess these individuals?
Ayman El arabishy: And your GW experience?
Kenneth Harwood: Has been very positive. I should tell you that – when I came here my wife also is a professor here so it was actually a very easy transition. So that was part of the positive experience that I came here with. But I also say one of the things that I enjoyed about GW when I came here and we talked about innovative and I think [Joe Bacino] the Dean, who hired me at the time, actually I didn’t necessarily fit into a perfect, you know, plug, I’m a physical therapist but I’m also an ergonomist, my interest is in health service research as well as safety and prevention.
Ayman El Tarabishy: And an entrepreneur.
Kenneth Harwood: And an entrepreneur and I’m old. There’s a lot of things I’ve had in my experiences. But what was really great about Joe and I think the institution was it allowed me to – they kind of helped me make a position. And certainly healthcare quality is my love at this point. I would certainly say if I could make a change in that I’m excited about doing that. I kind of hopefully inspire students to actually do it, I can’t do it as much as I would like to. So I think at this point it’s allowing me first of all to do the research that I want to do.
It was my first times as an online professor, I both do face to face and online. I think that experience has been an eye opener for me, I love it now. I think I actually get to know students better than face to face, which is somewhat counter intuitive but it actually is true. They don’t have a choice, they have to speak up because they have to write up in the discussion boards. So, therefore I actually get to see their thinking a lot more. So, at this point, you know, I feel like I’m still a novice even after 35 years of being in education I still feel challenged all the time.
Ayman El Tarabishy: That means you’re having fun.
Kenneth Harwood: It does mean that, right.
Ayman El Tarabishy: Thank you very much for your time. I appreciate it. And we’ll be back in touch with some questions from the students later on.
Kenneth Harwood: Okay, sounds good.
Ayman El Tarabishy: Okay. Hi everyone so this is a debrief for one of our sessions Dr. Howard here. So, a couple of things that come to my mind. First of all very, very interesting gentleman. He comes from many different domains here. You know, he’s a doctor, clinician, he’s a professor, a researcher, he owns his own business, he worked on a management role as well. So you can see multiple hats, multiple perspectives on understanding the issue at hand here and very energetic as well and it seems like he’s having a lot of fun doing what he’s doing here.
But what did we get out of this session? Many things, first of all this whole concept of value, now we’re talking about value for the patient, value for the hospital, value for the system, value for the people providing the service. Now we’re analyzing this whole situation from a value based system.
What surprised me is why is this so new? Why is value, the concept of value so new? From the business perspective if you do not provide a value nobody’s going to utilize your system, nobody’s going to buy your service, nobody’s going to buy your product. So, why in the healthcare industry value becomes such a critical issue right now, shouldn’t it have been before? Or is it a new terminology for something we should have been doing for a long period of time. Something to reflect upon here because coming from the business world this is not new for me, this is something that should have been on the table a long time ago. What is the value for the patient? The patient is also a customer, is also a consumer. So, we actually have to look at them from three different perspectives.