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Dr. Rhea Cohn

Dr. Rhea Cohn

Assistant Director of Clinical Education
Assistant Professor

The George Washington University
School of Medicine & Health Sciences

Future: Business of Healthcare Service Delivery

Transcript

Ayman El Tarabishy: Welcome back. It’s my privilege to have Dr. Cohn with us this afternoon for another session of our course. Let me introduce her by reading her biography. Throughout her professional career as a physical therapist, Dr. Cohn has remained dedicated to teaching. Audiences have included physical therapists, students and faculty, physical therapists, other healthcare professions and industry stakeholders including insurance representatives and investigators.

She has worked as a clinician, [unintelligible [00:00:57] management coordinator and professional director, advocating for national and local insurance regulation and payment policies that are favourable to physical therapist.

Dr. Cohn is currently a member of the Maryland Board of Physical Therapy Examiners. Bringing these multiple perspectives to the classroom, Dr. Cohn offers a wide view of industry issues and challenges facing physical therapists in today’s marketplace. She teaches administration and management, professional issues and team teaches in two critical conference courses. She’s also an assistance director of clinical education. Her goal is to help prepare program graduates with the skills necessary to successful practice in a rapidly changing healthcare industry. Thank you for joining us.

Dr. Cohn: You’re welcome.

Ayman El Tarabishy: So, we were just having a conversation before we went into full record mode here that this is your first time actually getting taped for an online class.

Dr. Cohn: Yes.

Ayman El Tarabishy: You’re more of classroom teacher.

Dr. Cohn: I am.

Ayman El Tarabishy: So, what do you think of online education?

Dr. Cohn: Well, I actually had participated myself in online education earlier in my career so I’m familiar with it. There was at that time less use of video and more use of really readings and discussion boards but less with video of the actual speakers. But I think for busy people who are really trying to move their career forward, it’s really nice to continue your education.

Ayman El Tarabishy: So, do you think teaching in the classroom or teaching online both have their pros and cons.

Dr. Cohn: Oh absolutely.

Ayman El Tarabishy: What’s the magic of online?

Dr. Cohn: The magic of online it can be a real time saver. You can do it from any location virtually. And if you’re a working person you can squeeze it in at night and not be limited to a career class schedule that is more, you know, typical of a traditional model.

Ayman El Tarabishy: You know they could be watching us on their cell phones right now.

Dr. Cohn: Yes they could be. [laughs]

Ayman El Tarabishy: Or an iPad or one of those tablets right there.

Dr. Cohn: Right.

Ayman El Tarabishy: It’s a whole new world. Let’s talk about this whole new world here. And we’ve scripted some questions here just to keep our focus for the segment here. I’m going to start with a very global question. But it will led into more granular questions here. So, let me start. What do you think, how might the business of delivering medical services change in the future?

Dr. Cohn: Well, the business not only will change it’s going to have to change. The traditional models of the business of healthcare were to provide services regardless of the outcome of care and get paid for those services. And the interest now in the industry is to pay for value, which we think of as outcomes over cost.

So, the outcomes of care are going to become increasingly important to measure and to report in order to get paid. And they’ll be increasingly probably incentive payments related to outcomes. So that people are going to be competing more on outcomes and less on just getting a volume of patients or procedures done for billing purposes.

Ayman El Tarabishy: So this is a recurring theme here, it’s value, value, value. But you mentioned as part of the biography I read here is that you were also dealing with a payment system here. So, here’s a follow up question here, how are the changes in payment methodologies for inpatient and outpatient services forcing distribution, disruption, I apologize, disruption in business models.

Dr. Cohn: Right so it’s like a big question. On the inpatient side the traditional payment methodology’s been perspective payment, where there’s a set fee usually based on a diagnostic group. And the hospitals or other facilities will get paid for a case, basically like a case.

And that is starting to shift because acute care hospitals are no longer going to be functioning in their own silo. That fragmentation of care that’s so pervasive in our system is going to be changing. Acute care is going to be starting to be bundled with post acute care services, there’s lots of different ways that can be combined. But there’s going to be more of a continuum being included under one payment bucket so to speak.

And that means that stakeholders are going to have to collaborate and understand what’s happening at different levels of care and they’re going to have to align their incentives. Right now with the fragmentation of care and the pipeline, having these different silos, the each individual level of care has its own incentives, its own payment methodologies, its own method of reporting, its own measurement tools. And that’s all going to have to change in order for the incentives to realign and the payments start to be grouped together.

Ayman El Tarabishy: So, let’s get in more detail here. So, this is an example, this is a personal example that I know of and it’s a real life example. I’m going to withhold names of hospitals and so on.

So, there is a patient, an international patient, that wanted to do a heart aortic valve replacement. They went to the hospital and they said at the hospital they said well I need you to do the surgery, I do not have insurance. But how much does it cost? So, the number they gave that person, that patient was close to about $200,000 for everything from intake to operation to post care. And they asked for down payment and they figured out a budget for them and everything.

Yet what happened while they’re negotiating this, the emergency happened and she actually had to go to the emergency care and under the law if you go to the emergency unit, they have to take you in and actually cover you. So, they did the surgery but as soon as they went into emergency care, because she was an international traveller, she was covered by the international insurance.

And the price that came back, the cost that came back under the medical insurance, actually what the hospital charged the insurance company was close to $50,000. Major discrepancy between $200,000 of what they were asking the patient to pay versus what they actually paid the insurance company. From a business side, they just lost a lot of business potentially. If they could have figured out a process in which they can actually explain the cost system to the patient, regardless of international or U.S citizen, why is this happening in the healthcare industry while in the private sector and business it’s very clear how pricing is done?

Dr. Cohn: Price transparency has not been a part of hospital care for a very long time and that’s well documented. And part of what’s happening is cost shifting on people who are cash based payment compared to people who services are being paid for by a third party. So, the hospitals will pre-negotiate rates with third parties, particularly if they’re a network provider hospital. And those are usually at a discount. And then they have to figure out how to make up the money that they’ve lost through the discount that’s been pre-negotiated. And that usually happens when they have cash based patients, so that cost shifting occurs to try to recover the money that they would have otherwise possibly gotten through contract.

Ayman El Tarabishy: So cost shifting, I like the word cost shifting but I’m having a hard time accepting it. Because in the private sector, you know, it doesn’t work that way. You know, cost shifting is not something people look favorably upon. You know, you do have, you know, a discount for wholesalers, you have a discount for repeat customers, you have a discount for repeat consumers etc. etc.

But in hospitals it’s kind of like a black box. And then we have the ACA and then we have a lot of initiatives coming in trying to streamline payments, to try to figure out exactly how to create efficiencies. From a business perspective, if you were a business perspective, isn’t this an opportunity for you to look into? But won’t there be resistance from hospitals and physicians and healthcare providers?

Dr. Cohn: Well, hospitals will do everything possible not to be transparent about their costs ’cause once you know their costs you’re going to have a better idea of what a payment should be. And so, I think they’re going to continue to try to shield the public from knowing what their true costs are. That’s very hard to figure out.
But the cost shifting is occurring throughout the industry. Look at the change in co-payments, there’s a rise in people’s responsibilities and their co-payments are much higher than they used to be. In fact some states have fair co-pay laws to make sure that there’s not too much shifted to the patient for out of pocket application. Deductibles have been rising throughout the industry, there’s a major change towards the use of more high deductible health plans. So, more cost shifting again onto the consumer, the patient or their family member. So, cost shifting is happening throughout the industry inpatient and outpatient.

Ayman El Tarabishy: So understanding that this is the norm or this is what’s happening here, how do we move from cost shifting to being a little bit more business agile and saying there’s a new model happening for here? What is your take on this, how do we move into that direction?

Dr. Cohn: Yeah so data, data, data, data, right? [laughs] That is absolutely going to be the key, is people who are going to understand and collect and use numbers to have what the Institute of Medicine calls a continuous learning system. We practice whether it be a private or whether it be a facility or a hospital or whatever it is, has to have ongoing use of review of data to help solve their problems, make decisions hopefully for the better, re-measure, revaluate, so it’s that PDSA cycle. And they’re really looking for people now to incorporate that as part of their day to day business as opposed to maybe a once every five year exercise that happens when a strategic plan is developed.

So, the electronic medical record is going to be offering clinicians and business people huge amounts of information. And the trick I think is going to be, on the business side, is going to be to pick the key points that have been entered into the medical record and the claim side. And pick out the metrics that are really going to help them sell their business problems and definitely how they’re going to be able to demonstrate their value.

Ayman El Tarabishy: So let’s talk about electronic medical records because that’s the main component of this class here. It can be used for a tool to garner more data to collect it and organize it into information, which translate into knowledge how we apply this. But at the same time it can be a tool to realize there’s inefficiencies in the system, people are being compensated more than they’re supposed to be and so on.

How do we balance this out? There’s change, there’s a lot of resistance to change and the reason there’s a lot of resistance to change is people fear the unknown. They don’t know what’s going to happen. Now we have this data coming up, they don’t know what to do with it ’cause it might show things we are really not ready to handle.
Dr. Cohn: Yeah. So, I think there’s always going to be an inherent tension in the medical fields between the clinician and the business side because sometimes the focus on patient care can be at conflict with what might be considered best business practice. Michael Porter from Harvard actually writes about integrative practice units, which are groups of clinicians and non clinicians who come together to treat patients with certain conditions, particularly high cost conditions. So think cardiac or Diabetes, cancer, arthritis, those are four of the big five conditions that cost a lot of money.

And so, I think one idea is to collaborate with more an inner professional team and figure out how to best use resources in the most efficient way without duplicating services, without wasting services, doing unnecessary tests that we know don’t work or don’t have any value and just add waste to the system.

And so the EMR is going to be away to help gather that kind of information to create the efficiencies, you know, what is helping our patient get better outcomes? We’re going to have to measure outcomes, we’re going to have to record the outcomes. And at the same time you have the business metrics coming in and the payments that you’re getting and you’re going to have to start figuring out how to measure how to improve those efficiencies and demonstrate value.

Ayman El Tarabishy: But that also relates to the compensation of the healthcare providers, the physicians because if EMR comes in and we have all these data points, then we can actually evaluate their productivity, right? And say well you’ve done X amount of work this year, that amounts to X amount of dollar value and this is what we’re paying you. That’s very controversial.

Dr. Cohn: Right. And measurements of productivity probably aren’t where they need to be in the medical field ’cause it’s not like widgets. And using billing units is not a good way to measure productive and we know that. But that’s what’s been used traditionally.

And so again, the issue is can we measure value, can we measure the outcomes of care? Did their patients get better? Did their patients get better faster than their colleague or a younger professional treating the patients? Did they use the same amount of tests, could they get better outcomes with less imaging, less labs, different number of visits? So, I think there’s going to be a lot of ways that clinicians and the business folks are going to have to figure out how to measure value. And then at the same time of course use the business metrics for things like productivity.

Ayman El Tarabishy: So there’s a tension coming.

Dr. Cohn: Yeah.

Ayman El Tarabishy: Or it’s here already ’cause I feel the tension. [laughs]

Dr. Cohn: [laughs]

Ayman El Tarabishy: I feel like I’m grilling you with these questions, I’m like what’s going on here? But let’s talk a little bit about why is there interprofessional collaboration so critical to business efficiency? And I love the word interprofessional because we are professionals, I’m in the business school, you’re in the school of medicine. But I feel like even though there’s a tension I also see that tension can create sparks for more energy.

Dr. Cohn: Absolutely right. So, I know on the medical side, and when I say medical I mean in its biggest sense, all healthcare providers, there’s really a push on the educational side to teach interprofessional collaboration. In fact we just had an exercise this week with four or five different healthcare professionals within the GW community to help our students understand how five different professionals would come together and create a plan of care for a patient with Multiple Sclerosis.

And so, we’re teaching out students how to understand what other people are coming to the table with in terms of their skill set and their perspective to treat a patient. That’s going to be very powerful. And that really speaks to Michael Porters IPUs, right? That a physician’s going to come to the table maybe with a keen interest in pharmaceuticals, medical management. A therapist might come to the table with a real interest in keeping the patient at home and functional and moving, mobile, walking. A speech language pathologist may come to the table wanting to help that patient with speech and swallowing issues and put it all together. And if you keep somebody functioning at a high level, their healthcare costs are less, right?

Ayman El Tarabishy: Let’s talk about the business language here. What you just mentioned to me here, I can break it down into features and benefits, which will equal to value. So, I can come in and say what are the features of this individual, this director, this clinician, this expert. And they say this person is an expert on this, this and this. And it goes from A to Z. So, these are their features, what they’re capable of doing, right? What are their benefits? It’s really business terms at its rudimentary, it’s business, features and benefits. And then which will lead into combining the features and benefits. You get to see the value of this person providing you that service.
That’s the direction of the business world. And we’re looking at comparison of different doctors, clinicians, you know, hospitals, right? You can come in, I hear it on the radio, so and so hospital is offering this, this, so and so is offering that. And they keep taking about their features, what are they featuring in their hospitals and what they’re providing and what are the benefits associated to this? Which will equal to value at the end.

Dr. Cohn: Hopefully.

Ayman El Tarabishy: Hopefully, exactly. That’s the question. Is it really worth it, right? But then there comes the, and I did use this word before, patients, we’re talking about patients. But these patients as well are consumers and also are customers, three different [unintelligible [00:19:18] are coming together. Yes you are a patient, which takes priority, but at the end you’re also a consumer of these services but you’re also again customer looking at how much you have to pay versus what’s providing what. How do we balance all of this?

Dr. Cohn: Yeah so that’s really interesting because increasingly you see literature referring to patient engagement and that with improved patient engagement, you’re going to get better outcomes and that speaks to the business side, reducing costs. So, if you can make sure your patients understand the instructions you give them, so you make it an appropriate literacy level. You actually can reduce medical errors; you can improve their outcomes because they’re self managing better. And they become part of the team. And that’s really sort of the new thought. And IPU thought is the same thing, that patient is actually part of the medical team now. They’re not a separate entity. And they have to be a collaborative part of the decision making.

And if we do that well actually we’re going to get better value, we’re going to get better outcomes at a reduced cost ’cause they’re going to understand. A good example would be do they understand discharge instructions from the hospital ’cause if they don’t they might be remitted. And we all know what happens now with hospital reemissions, the hospitals are penalized for reemissions. And so, if you give really good instructions when the person’s leaving the hospital there’s a better chance they won’t be reemitted.

Ayman El Tarabishy: Let’s talk future. What changes are on the horizon for providers, scope of practice and their [unintelligible [00:21:01] environment. What do you see happening in the future?

Dr. Cohn: So it’s very exciting. I think there’s going to be challenges in making sure that the regulatory side is keeping up with the technology side. And when I wear my regulatory hat on the [licensor] board in Maryland, I see coming up with Telehealth issues. That is a field that is growing very quickly, the technology gets better and better. And we’re going to have to make sure to ensure the public’s safety but at the same time Telehealth offers people access to services they wouldn’t have had, better communication, visualizing someone in their home environment, which is very huge ’cause you can actually see risks and problems in the home when you actually see somebody in their home space.

So, Telehealth is huge and very exciting. And I think the regulatory side is going to have to come up to speed pretty quickly to make sure that we are managing that ’cause the technology’s pretty much here and keeps getting better.

Ayman El Tarabishy: I’m excited about Telehealth. But I can – I’m just curious to see will doctors sit there.

Dr. Cohn: They are.

Ayman El Tarabishy: They are and I know some of them are doing it but we have, I guess we have different groups of doctors, the young ones, millennials that officially are coming in and find technology as just part of their day. But then there’s the other ones that technology is just a regular record, hand writing and now they’re moving into this domain. It’s exciting but at the same time it’s a little bit scary, what do you think?

Dr. Cohn: Yeah, I think, you know, again people are going to have to get trained and brought up to speed. I don’t think it’s going to be for everybody. I think some people might have a practice model where Telehealth is an important part of their practice model.

You know, patient portals aren’t going to be the only way that physicians are going to communicate with their patients anymore. In fact one of my most favourite books I read recently was by Eric Topol who’s a doctor and he wrote a book called The Patient Will See You Now. And it really flips the paradigm of who’s in charge and where the information is coming from and the idea of a use of a lot of mobile technology to track data, to acquire new data that gets sent to the physician electronically where the patient is not in the presence of the physician but decisions are made, communicated to the patient, treatment decisions are started, plan of cares are started. And that’s going to be a real game changer.

Ayman El Tarabishy: So I read an article and I was talking a little bit of knowledge management to this whole concept. And there was an article written about a doctor that was trying to diagnose a patient or an issue. And they were stuck. So, instead of just asking one or two individuals, they basically posted it to the whole network. And the whole network basically jumped in collectively together saying well have you thought of this, have you thought of that? And at the end, they realized, they figured out the issue here but it took actually a whole global network of experts and physicians coming in and saying have you considered this, have you considered that? That’s amazing.

Dr. Cohn: But isn’t that what grand rounds is now, right? I mean it happens now it’s just face to face instead of electronic collaboration.

Ayman El Tarabishy: Exactly. But imagine if big data starts to come in and the computer system that comes in and starts saying, you know, we’ve gotten so many requests on this based on our analysis this is what we’re thinking. Are we in this whole, somebody said Star Trek domain, are we in the Star Trek domain or are we still not in it.

Dr. Cohn: No, I think there’s going to be increasingly clinical decision support tools embedded into electronic medical records. Great examples would be dosing red flags if a physician prescribes a medication, the electronic medical record may pick up a dosing problem, may pick up a conflict with another medication. And just a notice pops up and says are you sure you want to prescribe this dose, the patient is already on such and such a drug, right?

So, that’s a great avenue to help check for somebody in terms of safety, risk management and good patient care. So, clinical practice guidelines are going hopefully going to be increasingly populated into electronic medical records for all disciplines and really help with decision making.

Ayman El Tarabishy: So we can blame the doctor if they make an error, can we blame the system if there is an error in the system?

Dr. Cohn: The jury’s out, right? [laughs]

Ayman El Tarabishy: I had to ask.

Dr. Cohn: Well, I think that’s got to get tested at some point and it will get tested. Who’s really ultimately making the decision? But at the end of the day, these clinical decision tools are really more like have you considered notices, ultimately the doc, like now if it’s a physician who’s involved in the case and treating that patient in the moment is going to have to make a decision if the say yep, I’ve made my decision and they hit enter, it’s a done deal, it’s still their responsibility. But the clinical decision support tools are really meant as have you thought of this, give it one more thought, right?

Ayman El Tarabishy: Can you confirm that you are going to – you confirmed.
Dr. Cohn: You’re saying me?
Ayman El Tarabishy: Yeah, can you confirm that you confirmed.
Dr. Cohn: [laughs] It’s a double check.
Ayman El Tarabishy: If we had this interview again let’s say five years from now, what’s the state that we’re going to be in?
Dr. Cohn: Oh wow.
Ayman El Tarabishy: I know things move real -
Dr. Cohn: They’re moving really quickly, yeah.
Ayman El Tarabishy: How would you see it in compensation and patient customer interaction and even the whole, industry as a whole?
Dr. Cohn: Big question. Compensation is probably going to have to get revamped because there’s going to be more collaborative payment models. So, what I am anticipating is that the hospitals are going to become more powerful ’cause they’re going to be responsible for managing that bucket of money that then has to get distributed. And so I think they’re going to be fairly key and have a fair amount of power in the new marketplace.

I think in terms of professionals, they’re just going to have to be better at collaborating and figuring out who their partners are. They’re not going to be able to work in silos anymore unless they’re a cash based business and don’t rely on any third parties.

Ayman El Tarabishy: Thank you for your time. This has been exhilarating.

Dr. Cohn: Thank you for having me.

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