Focusing the Health Care Lens

Lead Analyst: Maria DeGiglio

RFG Perspective: There are a myriad of components, participants, issues, and challenges that define health care in the United States today. To this end, we have identified five main components of health care: participants, regulation, cost, access to/provisioning of care, and technology – all of which intersect at many points. Health care executives -- whether payers, providers, regulators, or vendors – must understand these interrelationships, and how they continue to evolve, so as to proactively address them in their respective organizations in order to remain competitive.

This blog will discuss some key interrelationships among the aforementioned components and tease out some of the complexities inherent in the dependencies and co-dependences in the health care system and their effect on health care organizations.

The Three-Legged Stool:

One way to examine the health care system in the United States is through the interrelationship and interdependence among access to care, quality of care, and cost of care. If either access, quality, or cost is removed, the relationship (i.e., the stool) collapses. Let's examine each component.

Access to health care comprises several factors including having the ability to pay (e.g., through insurance and/or out of pocket) a health care facility that meets the health care need of the patient, transportation to and from that facility, and whatever post discharge orders must be filled (e.g., rehabilitation, pharmacy, etc.).

Quality of care includes, but is not limited to, a health care facility or physician's office that employs medical people with the skills to effectively diagnose and treat the specific health care condition realistically and satisfactorily. This means without error, without causing harm to the patient, and/or requiring the patient to make copious visits because the clinical talent is unable to correctly diagnose and treat the condition.

Lastly, cost of care comprises multiple sources including:
• Payment (possibly from several sources) for services rendered
• Insurance assignment (what the clinical entity agrees to accept from an insurance company whose insurance it accepts)
• Government reimbursement
• Tax write-offs
• The costs incurred by the clinical entity that delivers health care.

As previously mentioned, in this model, if one component or "leg" is removed the "stool" collapses.

If a patient has access to care and the means to pay, but the quality of care is sub-standard or even harmful resulting in further suffering or even death, the health care system has failed the patient.

If the patient has access to quality care, but is unable to afford it either because he/she lacks insurance or cannot pay out-of-pocket costs, then the system has once again failed the patient. It is important to note that because of the Federal Emergency Medical Treatment and Labor Act (EMTALA) an Emergency Department (ED) must evaluate a patient and if emergent treatment is required, the patient must be stabilized. However, the patient will then receive a bill for the full fees for service – not the discounted rates health care providers negotiate with insurance companies.

In the third scenario, if the patient lacks access to care because of distance, disability, or other transportation issues (this excludes ambulance), the system has again failed the patient because he/she cannot get to a place where he/she can get the necessary care (e.g., daily physical therapy, etc.).

This example of the interrelationship among access, quality, and cost underscores the fragile ecology of the health care system in the United States today and is call to action to payers, providers, and regulators to provide oversight and governance as well as transparency. Health care vendors affect and are affected by the interrelationship among access, quality, and cost. Prohibitive costs for payers and providers affect sales of vendor products and services or force vendors to dilute their offerings. Health care vendors can positively affect quality of health care that is provided by offering products to enable provider organizations to proactively oversee, trouble shoot, and remediate quality issues. They can affect cost as well by providing products and services that are not only compliant in the present but will continue to remain compliant as the policies change because there are both hard and soft dollar savings to providers.

Managing the Information, Not the Cost:

An example of what can sometimes be a paradoxical health care system interrelationship is that between the process of providing care and the actual efficient provisioning of quality care.

While most health care providers comply with the federal mandate to adopt electronic medical records by 2014, many are still struggling with manual processes, information silos, and issues of interconnectivity among disparate providers and payers. There is also the paradox of hospitals steadily closing their doors over the last 25 plus years and Emergency Departments (EDs) that continue to be crammed full of patients who must sometimes wait inordinate amounts of time to be triaged, treated, and admitted/discharged.

One barrier to prompt triage and treatment in an emergency department is process inefficiencies (or lack of qualified medical personnel). Take the example of a of a dying patient struggling to produce proof of insurance to the emergency department registrar – the gatekeeper to diagnosis and treatment – before collapsing dead on the hospital floor.

But the process goes beyond just proof of insurance and performing the intake. It extends to the ability to:
• Access existing electronic medical history
• Triage the patient, order labs, imaging, and/or other tests
• Compile results
• Make a correct diagnosis
• Correctly treat the patient
• Comply with federal/state regulations.

A breakdown in any of these steps in the process can negatively affect the health and well-being of the patient – and the reputation of the hospital.

Some providers have taken a hard look at their systems and streamlined and automated them as well as created more efficient workflow processes. These providers have been effective in both delivering prompt care and reducing both costs and patient grievances/complaints. One health care executive indicates that he advises his staff to manage the information rather than the money because the longer it takes to register a patient, triage that patient, refer him/her to a program, get him/her into the correct program, ensure the patient remains until treated, bill the correct payer, and get paid, the more money is lost.

The provisioning of satisfactory health care is related to both provider and payer process and workflow. By removing inefficiencies and waste and moving toward streamlining and standardizing processes and automating workflows health care provider executives will likely provide patients with better access to quality medical care that at reduced cost for their organizations.

The Letter of the Law:

Another tenuous interrelationship is among the law (specifically Health Insurance Portability and Accountability Act of 1996 (HIPAA)) and the enforcement thereof, technology (i.e., treatment of electronic medical records), and how provider organizations protect private health information (PHI) – or don't. Two incidents that made national news are discussed in the New York Times article by Milt Freudenheim, Robert Pear (2006) entitled "Health Hazard: Computers Spilling Your History." The two incidents:
(1) Former President Bill Clinton, who was admitted to New York-Presbyterian Hospital for heart surgery. (Hackers including hospital staff were trying to access President Clinton's electronic medical records and his patient care plan.)
(2) Nixzmary Brown, the seven-year-old who was beaten to death by her stepfather. (According to the Times, the New York City public hospital system reported that "dozens" of employees at one of its Brooklyn medical centers had illegally accessed Nixzmary's electronic medical records.)

These two incidents, and there have certainly been many more, illustrate the tenuous interrelationship among a law that was passed, in part, to protect private health information, abuses that have been perpetrated, and the responsibility of health care organizations to their patients right to privacy and confidentiality.

Progress has been and is being made with:
• More stringent self-policing and punitive measures
• Use of more sophisticated applications to track staff member log-ons and only permitting staff who have direct contact with a patient to see that patient's electronic medical records
• Hiring, or promoting from within, IT compliance officers who understand the business, the law, and technology to ensure that patient information is handled in a compliant manner within health care facilities' walls as well as preventing outside breaches.

Compliance with privacy laws is dependent upon being able to enforce those laws, and having processes and technology in place that detect, identify, report, and prevent abuses. Technology is far ahead of the laws and policies that govern it. Moreover, the creation of law does not always go hand-in-hand with its enforcement. Health care technology vendors must work with their provider customers to better understand their environments and to craft products that enable health care providers to safeguard PHI and remain compliant. Health care regulators must continuously address how to regulate new and emerging technologies as well as how to enforce them.

Summary

The above are just three examples of the myriad interrelationships among the aforementioned health care components. It is clear that no one element stands alone and that all are interconnected, many in innumerable ways. It also underscores the fact that health care executives, whether payers, providers, vendors, etc. must understand these interrelationships and how they can help/harm their respective organizations - and patients.

RFG POV: Health care executives are challenged to develop and deliver solutions even though the state of the industry is in flux and the risk of missing the mark can be high. Therefore, executives should continuously ferret out the changing requirements, understand applicability, and find ways to strengthen existing, and forge new, interrelationships and solution offerings. To minimize risks executives need to create flexible processes and agile, modular solutions that can be easily adjusted to meet the latest marketplace demands.

Blog: Data Center Optimization Planning

Lead Analyst: Cal Braunstein

Every organization should be performing a data center optimization planning effort at least annually. The rate of technology change and the exploding requirements for capacity demand IT shops challenge their assumptions yearly and revisit best practices to see how they can further optimize their operations. Keeping up with storage capacity requirements with flat budgets can be a challenge in that capacity is growing between 20-40 percent annually. This phenomenon is occurring across the IT landscape. Thus, if IT executives want to transform their operations from spending 70-80 percent of their budgets on operations to more than half the budget spent on development and innovation instead, executives must invest in planning that enables such change.

Optimization planning needs to cover all areas of the data center:

• facilities,
• finance,
• governance,
• IT infrastructure and systems,
• processes, and
• staffing.

RFG finds most companies are greatly overspending due to the inefficiencies of continuing along non-optimized paths in each of the areas; thereby providing companies with the opportunity to reduce operational expenses by more than 10 percent per year for the next decade. In fact, in some areas more than 20 percent could be shaved off.

Facilities.  At a high level, the three areas that IT executives should understand, evaluate, and monitor are facilities design and engineering, power usage effectiveness (PUE), and temperature. Most data center facilities were designed to handle the equipment of the previous century. Times and technologies have changed significantly since then and the designs and engineering assumptions and actual implementations need to be reevaluated. In a similar vein, the PUE for must data centers is far from optimized, which could be resulting in overpaying energy bills by more than 40 percent. On the "easy to fix" front, companies can raise their data center temperatures to normal room temperature or higher, with temperatures in the 80° F range being possible. Just about all equipment built today is designed to operate at temperatures greater than 100° F. For every degree raised organizations can expect to see power costs reduced by up to four percent. Additionally, facilities and IT executives can monitor their greenhouse gas (GHG) emissions, which are frequently tracked by chief sustainability officers and can be used as a measure of savings achieved by IT operational efficiency gains.

Finance.  IT costs can be reduced through use of four key factors: asset management, chargebacks, life cycle management, and procurement. RFG finds many companies are not handling asset management well, which is resulting in an overage of hardware and software being paid for annually. Studies have found this excess cost could easily run up to 20 percent of all expenses for end-user devices. The use of chargebacks better ensures IT costs are aligned with user requirements. This especially comes into play when funding external and internal support services. When it comes to life cycle management, RFG finds too many companies are retaining hardware too long. The optimal life span for servers and storage is 36-40 months. Companies that retain this equipment for longer periods can be driving up their overall costs by more than 20 percent. Moreover, the one area that IT consistently fails to understand and underperforms on is procurement. When proper procurement processes and procedures are not followed and standardized, IT can easily spend 50 percent more on hardware, software and services.

Governance.  The reason governance is a key area of focus is that governance assures performance targets are established and tracked and that an ongoing continuous improvement program is getting the attention it needs. Additionally, governance can ensure that the reasonable risk exposure levels are maintained while the transformation is ongoing.

IT infrastructure and systems.  For each of the IT components – applications, networks, servers, and storage – IT executives should be able to monitor availability, utilization levels, and virtualization levels as well as automation level. The greater the levels the fewer human resources required to support the operations and the more staffing becomes an independent variable, rather than one dependent upon the numbers and types of hardware  and software used. Companies also frequently fail to match workload types to the infrastructure most optimized to those workloads, resulting in overspend that can reach 15-30 percent of operating costs for those systems.

Processes.  The major processes that IT management should be following are application instances (especially CRM and ERP), capacity management, provisioning (and decommissioning) rates, storage tiers, and service levels. The better a company is at capacity planning (and use of clouds) the lower the cost of operations. The faster the provisioning capability the fewer human resources required to support operational changes and the likelihood of less downtime due to human error. Additionally, RFG finds the more storage tiers and automation of movement of data amongst tiers the greater the savings. As a rule of thumb organizations should find the savings as one moves from tier n to tier n+1 to be 50 percent. In addition to tiering, compression and deduplication are other approaches to storage optimization.

Staffing.  For most companies today, staffing levels are directly proportional to the number of servers, storage, network nodes, etc. The shift to virtualization and automatic orchestration of activities breaks that bond. RFG finds it is now possible for hundreds of servers to be supported by a single administrator and tens to hundreds of terabytes handled by a single database administrator. IT executives should also be looking to cross-pollinate staff so that an administrator can support and of the hardware and operating systems.

The above possibilities are what exist today. Technology is constantly improving. The gains will be even greater as time goes on, especially since the technical improvements are more exponential than linear. IT executives should be able to plug these concepts into development of a data center optimization plan and then monitor results on an ongoing basis.

RFG POV: There still remains tremendous waste in the way IT operations are run today. IT executives should be able to reduce costs by more than 40 percent, enabling them to invest more in enhancing current applications and innovation than in keeping the lights on. Moreover, IT executives should be able to cut annual costs by 10 percent per year and potentially keep 40 percent of the savings to invest in self-funding new solutions that can further improve operations.