October 31, 2024 • 18 mins
Lengthy emergency department wait times are nothing new. This has been a national issue since the 1980s. It's a challenge for every health system - a challenge with no easy solutions.
ChristianaCare is home to America's 15th busiest ED, and in this replay of one of our most popular episodes, "The Toughest Questions in Health Care," Dr. Kert Anzilotti, ChristianaCare Chief Medical Officer, and Ric Cuming, ChristianaCare Chief Operating Officer, deliver insightful answers to the question, "Why can ED wait times be so long?".
Together, we walk the complex maze of healthcare efficiency, examining the intricacies behind long queues. Learn how factors like hospital-wide patient volume, case severity prioritization and the ripple effects of post-acute care facility shortages contribute to a significant bottleneck. And explore a data-driven approach to improving patient flow and emergency department functionality.
Finally, we provide guidance on choosing the most suitable venue of care for a variety of medical needs, a major way the public can be part of helping hospitals reduce wait times in the ED.
Ric Cuming is chief operating officer of ChristianaCare. In this role, Ric oversees the delivery of efficient and fiscally responsible system operations. He also works with other leaders to ensure high-quality and safe patient care. Ric joined ChristianaCare in 2016 as the system’s first chief nurse executive.
Dr. Kert Anzilotti is chief medical officer for ChristianaCare. His work focuses on the optimization of care delivery across the health care system through strategic visioning, network development, clinical technology implementation and leveraging medical informatics.
Links
- Should I Go To the Emergency Room, Urgent Care or Primary Care?
- Emergency Care at ChristianaCare
- ER visits are getting longer amid hospital staffing shortages
- The Complexities Of Emergency Medicine And Prolonged ER Wait Times
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
Hello everyone, I'm Megan McGerman.
Speaker 2 (00:02):
And I'm Jason Tokarski.
Welcome to For the Love ofHealth brought to you by
Christiana Care.
Speaker 1 (00:06):
We're taking a few-week break from new content,
so we're bringing back some ofour most popular For the Love of
Health episodes.
Speaker 2 (00:14):
It's important to know when to visit the emergency
room urgent care or primarycare in case sickness or
injuries happen.
Today we're resharing one ofour toughest questions in
healthcare why can emergencydepartment wait times be so long
?
Speaker 3 (00:27):
With Rick Cumming and Dr Kurt Anzalotti, Hospitals
will lead the way in drivingcosts down for overall
healthcare spend into the future.
Speaker 2 (00:39):
You're listening to For the Love of Health, a
podcast about delivering careand creating health, brought to
you by Christiana Care.
And now here are your hosts.
Speaker 1 (00:49):
Hello everyone, I'm Megan McGerman.
Speaker 2 (00:50):
And I'm Jason Tokarski.
Welcome to another episode ofFor the Love of Health brought
to you by Christiana Care.
Speaker 1 (00:56):
If you've ever received medical care, you'd
likely agree the cost of carecan be expensive.
According to the NationalHealth Expenditure Accounts, US
health care spending grew 4.1percent in 2022, reaching $4.5
trillion.
Speaker 2 (01:13):
It's a complicated topic with a lot of contributing
factors.
So for the fifth episode of ourToughest Questions in Health
Care series, we're asking thequestion why is the cost of
health care so expensive?
Speaker 1 (01:24):
Here to help us tackle that question are
ChristianaCare Chief FinancialOfficer Rob McMurray, and
ChristianaCare Chief PopulationHealth Officer, dr Chris
Donahue-Henry.
Rob and Chris, thank you bothso much for your time today.
Speaker 3 (01:37):
Megan thanks.
Thanks for having us here.
Speaker 4 (01:38):
Yeah, we're glad to be here.
Speaker 1 (01:40):
Obviously, the cost of care is a complex topic,
hence why it's one of ourtoughest questions in health
care.
How can we explain it to thegeneral audience so that they
truly understand how cost ofcare works?
Speaker 3 (01:53):
You know, when we talk about the cost of care,
really what we're referring tois health spend and those
numbers you mentioned a momentago refer to national health
spend.
There's a lot of components ofthat Hospitals, which is what we
are most familiar with.
Hospitals represent about 30percent of health spend.
There's a lot of components ofthat Hospitals, which is what we
are most familiar with.
Hospitals represent about 30%of that spend.
So across the country we maythink when we think about
healthcare, we think hospitals.
Right, because it's what weassociate with.
(02:14):
We see them, we go to them, weknow where they are, they're
important to us as a community.
Hospital care is only 30% ofthat spend.
Physician care is roughly 14 to15% of the total health spend.
So combined hospitals andphysician care is less than 50%
of the total spend.
So it's really important tomaybe unpack what those numbers
(02:37):
are and those increases.
You mentioned a 4.1% increaseand really what's interesting to
me, when you look at the dataand the four years leading up to
the pandemic, 4.1% is lowerthan any of those year increases
.
When you look at, then, thedifferent types of spend,
hospital spend went up about2.2% this past year, so 4.1% in
(03:00):
total.
2.2% was hospitals and I thinkphysician was closer to 2.5%.
So 45% of the total spendincreased between two and two
and a half percent.
So the other 55%, what's inthere?
That's really important tounpack as we want to analyze
spending.
So what might be in there?
(03:20):
You have things like skillednursing facilities, home health.
There may be insurance costs.
Pharmaceuticals is in there.
You have things like skillednursing facilities, home health,
there may be insurance costs.
Pharmaceuticals is in there,right.
And when you look then at otherincreases, you see that this
past year, pharmaceuticalsincreased eight and a half
percent.
So it's important, while wetalk about an important spend
like healthcare across thecountry, to unpack those and
(03:42):
then really see what the driversare, because that helps shape
our strategy at Christiana Careand define some of what we're
going to do about it.
Speaker 1 (03:52):
So if those are the components of cost, how is
health care paid for?
Speaker 3 (03:56):
In several ways.
There is insurance.
Most of us who are employedhave some type of
employer-sponsored insurance.
There's also governmentalpayers, like Medicare or
Medicaid, and then there's asmall portion of the country
that goes without insurance.
So those are the, I'll say, thecategories of insurance, or how
healthcare is paid for.
Speaker 2 (04:15):
Obviously, there are multiple payers involved when it
comes to paying for healthcare.
What is the current mix ofpayers?
What does that look like in thesystem?
Speaker 3 (04:23):
At Christiana Care, what I can speak to, what we
reflect, is somewhat what yousee across the country.
Two-thirds of our payer isgovernmental programs, medicare,
medicaid.
About 30% is commercialinsurance or employer sponsored
insurance.
So if you're an employee, youhave an employee health plan
that typically carriescommercial insurance.
(04:44):
That's about 30% and then theremainder again is those who may
not have insurance.
And what's really important tonote from my perspective is to
think about those differentpayer categories.
So for ChristianaCare,two-thirds of the work our
caregivers do taking care ofpatients, two-thirds of the work
(05:06):
our caregivers do taking careof patients, two-thirds of the
work is for people who havegovernmental insurance, medicare
or Medicaid predominantly.
And why is that important?
Well, when you think aboutthings like the cost of care and
the cost to provide care,medicare and Medicaid on average
, this past year raised ourrates, our reimbursement rates,
(05:33):
less than 2%.
So the cost of care toChristianaCare is really
important and we have a lot ofstrategies in place driven at
the quality of care and the costof care.
Speaker 4 (05:38):
That's exactly right, rob.
In fact, we've had our MedicareACO since 2016, really focused
on our Medicare patients.
Similarly, our Medicaid ACOlaunched in 2021.
And that is really an alternatepayment model by which we can
better address a patient'squality outcomes and total cost
(05:59):
of care, really by focusing oncare coordination and how we
transition patients through thesystem and, ideally, really care
for them in the outpatientsetting.
Speaker 1 (06:09):
So those ACOs, accountable care organizations
what kind of success have you?
Speaker 4 (06:13):
seen with those.
So in our Medicare ACO we havesaved CMS $54 million since we
started and then similarly withthe Medicaid ACO.
We actually started with asignificant downside arrangement
with Medicaid in 2019.
And through now from 2019, wehave saved the state $7.7
(06:36):
million.
Speaker 2 (06:38):
So what are the key drivers of costs in healthcare
plans at this point?
Speaker 3 (06:42):
You know, the drivers for the cost of anything really
come down to two broadcomponents.
There's the cost to providethat service, whatever it may be
, and then there's the demandfor that service, the usage of
that service, or in healthcare,what we like to say is the
utilization of those services.
That's really important.
When we investigate the cost ofcare and why health care is
(07:03):
expensive, how does that playout?
Well, you think about a patient.
A patient has insurance,whether it's governmental or
employee-sponsored, whatever itmay be.
They're making decisions.
They're making decisions eitheron their own or, preferably
with the advice of a physician,on where they're going to get
care, what care they're going toget and when they're going to
(07:25):
get that care.
Those three pieces right welike to say right care, right
place, right time.
It's really important.
It's not a cliche, because thatwill drive costs of care.
Where I think it's important toinvestigate or consider is what
drives human behavior.
When you look at things likeutilization drives human
(07:46):
behavior.
When you look at things likeutilization, there are employers
who have sponsored health plansthat do not have that
creativity built into theirhealth plans.
There are no incentives ordisincentives for their
population and, as a result,their experiences are higher
cost of care, they have higherutilization, they have a higher
cost trend and ultimately theyhave less healthy employees and
(08:08):
dependents and it's because theyhaven't designed their health
plan accordingly to drive theright results.
You can put design functions inplace so that employees,
consumers of care, will likelysee their primary care physician
, maybe on an annual basis,depending on the features of the
(08:30):
plan.
Maybe they'll have programslike tobacco cessation, for
example.
Maybe there'll be disincentivesthat will essentially pass more
of the cost of an emergencydepartment visit to that plan
participant or that employee,because you don't want somebody
that doesn't need to go to theemergency department to go to
the emergency department.
Speaker 4 (08:48):
With our benefits team here at Christiana Care.
We sat down probably threeyears ago and talked about the
health risk assessments thatmany employers do for their
employees and the fact thatthere's really no evidence to
show that that drives down thecost of care.
What does is connection to aprimary care provider.
(09:09):
It improves screening forhealth conditions and it
improves the total cost of care.
So we actually changed ourbenefit design here at
Christiana Care in order toincentivize that primary care
visit and saw significantlyincreased use of primary care
through doing that and, as aresult, a decrease in our total
(09:30):
cost of care.
Speaker 3 (09:31):
So it absolutely played out here and continues to
so what I hear you saying is,by shaping those, those benefits
, the behaviors we're drivingcare to a lower cost setting,
avoiding a higher cost setting,driving down cost overall.
And I think what I hear youalso saying is we have healthy
people, healthier people as aresult.
Speaker 4 (09:53):
Absolutely.
Speaker 3 (09:54):
So the benefit of that, the overall benefit of
that, is healthier peopleutilizing the right care at a
lower cost, greater productivityout of those healthier people
as well.
Speaker 1 (10:04):
As you're having these internal conversations,
you're also focusing onvalue-based care.
Can you walk us?
Speaker 4 (10:10):
through that Sure.
So value-based care essentiallyis population health.
So how you manage a populationof patients and generally we
think about a population as apopulation under a payer so
Medicaid, medicare or differentcommercial insurance and in that
model there are expectations tomeet quality measures and then
(10:33):
expectations around total costof care.
So if you're able to decreasecost year over year while
maintaining or increasingquality for that population,
there's an opportunity for boththe health provider and the
payer to share in that savingsand ideally that share in the
savings that the payer receivesalso goes on to improve the
(10:57):
dollars back to the employer.
So it helps the affordabilityof that care as well.
Speaker 1 (11:01):
Chris, you are a primary care physician.
How does this improve care forthe patient?
Speaker 4 (11:07):
The way that this improves care is it drives
primary care docs to engageregularly with their patients,
and we talk about not justvisits with patients but the
time between visits whenpatients may have questions, may
have concerns about medication,may have side effects that they
need to talk to a clinicianabout, and what we're really
(11:28):
working on at Christiana Care isbuilding that infrastructure
for the between-visit care,working to build care management
functions through CareVO,working in our practices to set
up digital ways to connect withpatients and work on our triage
process across the medical group.
So all these play into bettercare for patients between those
(11:50):
visits, which ultimately leadsto better chronic disease
management, better cancerscreening, better control of
behavioral health conditions,which also are significant
factors here, but overall leadsto improved health of our
populations we serve leads toimproved health of our
(12:11):
populations we serve.
Speaker 1 (12:11):
So in the national conversation of value based care
, I've heard the term riskassociated with this.
How is it?
Speaker 4 (12:15):
a risk?
Well, it's a risk in the sensethat if you commit to decreasing
the total cost of care and youdon't achieve a decrease, then
that loss, if you will, isshared between the payer and the
provider.
Speaker 2 (12:30):
So we've talked a lot about quality of care and
efficiency and wellness.
Dive a little deeper into that.
What are we doing here,specifically at Christiana Care,
to get further into thiscontrolling of cost?
Speaker 4 (12:41):
So over the last many , many years Christiana has been
focused on our inpatientquality, driving to centers of
excellence in our hospital,working with hospital-acquired
infections, zero harm, and thatwork has been tremendous.
At the same time, we've beenbuilding our capabilities in the
outpatient space to bettermanage patients to keep them out
(13:04):
of the hospital.
Our next horizon is really tobring the two together to think
about how the whole carecontinuum is focused on
population health and that meanslength of stay.
How are we getting patients whodo need to be admitted in the
door the right care as quicklyas possible and have them go
home at a reasonable timeframeand really focusing on
(13:26):
efficiency overall and Project.
Speaker 3 (13:29):
Bedrock Project.
Bedrock is an enterprise-wideproject that is focused on
driving operational performanceright.
So it's across the clinicalspectrum, it's across the
administrative spectrum, allacross the organization, in
really driving down overall costand looking at ways that we can
(13:51):
be more efficient, changingwhat we do, changing how we
think, changing how we workright to become more efficient.
At Christiana Care we launchedthis project about a year and a
half ago.
We've paired up administrativeleaders with clinical leaders
and gone after projects to saywhat can we do differently about
(14:13):
, let's say, efficiencies in anoperating room?
And we have a very formalized,rigid structure to identify what
these opportunities are.
We measure them and then wereport back.
This happens on a weekly basis.
There's other work streams aswell.
One of those is supply chainright.
So we look at ways that we canget better contracts with our
supplier, providers, useproducts more efficiently and so
(14:37):
forth, looking to driveefficiencies to drive down that
cost.
We've realized we have aresponsibility at Christiana
Care to help control that costof health spend.
Even though the hospitals areonly 30%, we are looking broader
, across all of healthcare todrive that down.
Speaker 2 (14:54):
Recently, ChristianaCare was ranked as the
number five health system byMoney Magazine, which is awesome
.
Congratulations.
Money Magazine gaveChristianaCare an A for price
transparency.
What does that mean?
What is price transparency andhow does that benefit the
community?
Speaker 3 (15:09):
And aside from Money Magazine, there is an
independent price transparencyverification provider called
Turquoise.
Turquoise gave us their highestlevel, their highest rating.
We were the first hospital andhealth system in Delaware and in
the region to get that highestrating.
It is about making transparentthe costs for the services we
provide to patients, so thatcould be on a procedure by
(15:32):
procedure or visit by visit,whatever those services are.
We've posted those charges andthen mapped it against the major
insurance providers to say thisis what you can expect to pay
when you come to ChristianaCarefor that service.
At ChristianaCare there's a keyword in our mission and that's
(15:53):
called value, and we want all ofthe people that we serve in all
the communities we serve, tounderstand that value, but it's
the value through their lens.
So we'll give them tools likeposting our charges online to
show that transparency.
And we also offer ability forpatients or members of the
community to give us a call andwe have counselors and other
(16:14):
assistants to help withunderstanding what the costs of
care are, because they arecomplex.
It goes beyond pricetransparency but it really
supports it.
When you look at the ways thatwe bill people, we are looking
at friendly billing options andsome of those are electronic.
So if you go to your doctor atChristiana Care, you can have
(16:37):
the opportunity to have yourbill sent to you via text or an
email.
And what's really interesting inthis, and where I see the value
, is that there's a feedbackloop with this transaction.
So if I'm a patient and I get abill from my doctor, I can pay
it online on my phone, review orprovide feedback about my visit
.
I can provide feedback aboutthe payment.
(16:59):
We had a patient and she usedthis transparent payment system
and provided feedback, and herfeedback was I didn't realize
that I could take advantage of apayment plan for my services.
What really was important andwhat this patient said was I
have trouble paying for my care.
I was going to avoid care.
(17:21):
I was not going to go back tothe doctor because I didn't
think I could afford it, butwith a payment plan, I realized
that I can and I'm going to getthat care.
That's transparency in action.
That is the value oftransparency whether it's on a
website with charges, whetherit's a phone call or whether if
it's the way we can help billpeople and provide that feedback
(17:43):
loop, is really important.
Speaker 4 (17:45):
Rob, that is so important.
I can't tell you how many timesI've had the experience of
having a patient bring in a billfrom an inpatient stay and be
very, very concerned about thecharges.
They're not understanding thiswas in the past and another
health system, but it really hasthe potential to get in the way
of healing for that patientjust having been admitted and
(18:08):
really goes such a long way topromoting their wellness
long-term.
Speaker 1 (18:12):
And Chris, let's dive a little bit deeper into that
your experience in primary care.
Why is this so important, atthe end of the day, for the
average listener right now?
Speaker 4 (18:23):
I went into primary care because I believe in
prevention, I believe inwellness, I believe in keeping
people healthy.
I believe value-based care isthe way we can do this together
because it allows for adifferent payment model that
doesn't incentivize frequenthospital utilization.
In these type of payment models, it incentivizes us building
(18:46):
infrastructure to keep patientshealthier and out of the
hospital.
Speaker 2 (18:50):
This is part of our series of the toughest questions
in health care, and it's notjust about what's happening
right now.
It's, you know, using thecrystal ball to look a little
bit into the future.
So what does the future ofhealthcare costs look like to
each of you?
Speaker 3 (19:04):
I wish I had the crystal ball to tell you, but
what I will say is I amoptimistic about the cost of
care going forward.
We shared some stats earlier.
We talked about that 4%increase year over year.
Hospitals and physicians are atto two and a half percent.
What we are doing is startingto make a difference, as Chris
mentioned a moment ago.
When you talk about value-basedprograms, you talk about the
(19:26):
investments we are making right,whether it's a project bedrock
internally that's focused onefficiencies, or where we are
making investments for places toget care.
What do I mean by that?
We recently announcedneighborhood hospitals that we
are investing in.
So you're talking about a lowercost setting to provide care.
We have partnered with someprivate physicians on ambulatory
(19:50):
surgery centers.
In the area we have three ofthose that takes a surgery that
could be done in a higher costenvironment in an acute care
facility into an ambulatorysurgery center same quality,
lower cost, better experience.
Right Now, there's always areason to have certain surgeries
in the hospital, those that canbe moved out.
(20:10):
We are doing that.
That is less revenue for us asa health system, but we know
it's the right thing for thepatient and it drives down cost.
We are also investing intechnologies.
We're talking about things likehospital at home.
We're talking about things likevirtual nursing, skilled
nursing at home.
Right, these are right care,right place, right time.
This is about getting care in ahome.
(20:31):
It's cheaper, it's betterexperience, it's better in the
long term.
I am highly optimistic andconfident that hospitals will
lead the way in driving costsdown for overall healthcare
spend into the future.
Speaker 4 (20:43):
I totally agree, rob.
I am absolutely optimisticabout the future.
Our strategic plan atChristianaCare is completely
focused on being successful inpopulation health and doing the
things we need to do, making thechanges, population health and
doing the things we need to do,making the changes, making the
commitments we need to propel usforward.
I can tell you that ourclinicians are also very
(21:04):
invigorated by this model,thinking about how to care for
patients in a different and abetter way, and those are the
conversations that we're havingacross the organization and
really just see unlimitedpotential in the future.
Speaker 1 (21:18):
Rob and Chris.
Thank you both so much for yourtime today.
Thank you.
Speaker 2 (21:21):
We'll have more information on the cost of care,
including a link to ChristianaCare's price transparency site
in the show notes atchristianacareorg.
Speaker 1 (21:29):
And while you're there, you can subscribe to For
the Love of Health on ApplePodcasts or Spotify and follow
Christiana Care on social media.
Speaker 2 (21:36):
We'll be back in two weeks with another great
conversation.
Speaker 1 (21:39):
Until then, thanks for joining us for.
Speaker 2 (21:41):
The Love of Health.
Hello everyone, I'm Megan McGerman.
Speaker 2 (00:02):
And I'm Jason Tokarski.
Welcome to For the Love ofHealth brought to you by
Christiana Care.
Speaker 1 (00:06):
We're taking a few-week break from new content,
so we're bringing back some ofour most popular For the Love of
Health episodes.
Speaker 2 (00:14):
It's important to know when to visit the emergency
room urgent care or primarycare in case sickness or
injuries happen.
Today we're resharing one ofour toughest questions in
healthcare why can emergencydepartment wait times be so long
?
Speaker 3 (00:27):
With Rick Cumming and Dr Kurt Anzalotti, Hospitals
will lead the way in drivingcosts down for overall
healthcare spend into the future.
Speaker 2 (00:39):
You're listening to For the Love of Health, a
podcast about delivering careand creating health, brought to
you by Christiana Care.
And now here are your hosts.
Speaker 1 (00:49):
Hello everyone, I'm Megan McGerman.
Speaker 2 (00:50):
And I'm Jason Tokarski.
Welcome to another episode ofFor the Love of Health brought
to you by Christiana Care.
Speaker 1 (00:56):
If you've ever received medical care, you'd
likely agree the cost of carecan be expensive.
According to the NationalHealth Expenditure Accounts, US
health care spending grew 4.1percent in 2022, reaching $4.5
trillion.
Speaker 2 (01:13):
It's a complicated topic with a lot of contributing
factors.
So for the fifth episode of ourToughest Questions in Health
Care series, we're asking thequestion why is the cost of
health care so expensive?
Speaker 1 (01:24):
Here to help us tackle that question are
ChristianaCare Chief FinancialOfficer Rob McMurray, and
ChristianaCare Chief PopulationHealth Officer, dr Chris
Donahue-Henry.
Rob and Chris, thank you bothso much for your time today.
Speaker 3 (01:37):
Megan thanks.
Thanks for having us here.
Speaker 4 (01:38):
Yeah, we're glad to be here.
Speaker 1 (01:40):
Obviously, the cost of care is a complex topic,
hence why it's one of ourtoughest questions in health
care.
How can we explain it to thegeneral audience so that they
truly understand how cost ofcare works?
Speaker 3 (01:53):
You know, when we talk about the cost of care,
really what we're referring tois health spend and those
numbers you mentioned a momentago refer to national health
spend.
There's a lot of components ofthat Hospitals, which is what we
are most familiar with.
Hospitals represent about 30percent of health spend.
There's a lot of components ofthat Hospitals, which is what we
are most familiar with.
Hospitals represent about 30%of that spend.
So across the country we maythink when we think about
healthcare, we think hospitals.
Right, because it's what weassociate with.
(02:14):
We see them, we go to them, weknow where they are, they're
important to us as a community.
Hospital care is only 30% ofthat spend.
Physician care is roughly 14 to15% of the total health spend.
So combined hospitals andphysician care is less than 50%
of the total spend.
So it's really important tomaybe unpack what those numbers
(02:37):
are and those increases.
You mentioned a 4.1% increaseand really what's interesting to
me, when you look at the dataand the four years leading up to
the pandemic, 4.1% is lowerthan any of those year increases
.
When you look at, then, thedifferent types of spend,
hospital spend went up about2.2% this past year, so 4.1% in
(03:00):
total.
2.2% was hospitals and I thinkphysician was closer to 2.5%.
So 45% of the total spendincreased between two and two
and a half percent.
So the other 55%, what's inthere?
That's really important tounpack as we want to analyze
spending.
So what might be in there?
(03:20):
You have things like skillednursing facilities, home health.
There may be insurance costs.
Pharmaceuticals is in there.
You have things like skillednursing facilities, home health,
there may be insurance costs.
Pharmaceuticals is in there,right.
And when you look then at otherincreases, you see that this
past year, pharmaceuticalsincreased eight and a half
percent.
So it's important, while wetalk about an important spend
like healthcare across thecountry, to unpack those and
(03:42):
then really see what the driversare, because that helps shape
our strategy at Christiana Careand define some of what we're
going to do about it.
Speaker 1 (03:52):
So if those are the components of cost, how is
health care paid for?
Speaker 3 (03:56):
In several ways.
There is insurance.
Most of us who are employedhave some type of
employer-sponsored insurance.
There's also governmentalpayers, like Medicare or
Medicaid, and then there's asmall portion of the country
that goes without insurance.
So those are the, I'll say, thecategories of insurance, or how
healthcare is paid for.
Speaker 2 (04:15):
Obviously, there are multiple payers involved when it
comes to paying for healthcare.
What is the current mix ofpayers?
What does that look like in thesystem?
Speaker 3 (04:23):
At Christiana Care, what I can speak to, what we
reflect, is somewhat what yousee across the country.
Two-thirds of our payer isgovernmental programs, medicare,
medicaid.
About 30% is commercialinsurance or employer sponsored
insurance.
So if you're an employee, youhave an employee health plan
that typically carriescommercial insurance.
(04:44):
That's about 30% and then theremainder again is those who may
not have insurance.
And what's really important tonote from my perspective is to
think about those differentpayer categories.
So for ChristianaCare,two-thirds of the work our
caregivers do taking care ofpatients, two-thirds of the work
(05:06):
our caregivers do taking careof patients, two-thirds of the
work is for people who havegovernmental insurance, medicare
or Medicaid predominantly.
And why is that important?
Well, when you think aboutthings like the cost of care and
the cost to provide care,medicare and Medicaid on average
, this past year raised ourrates, our reimbursement rates,
(05:33):
less than 2%.
So the cost of care toChristianaCare is really
important and we have a lot ofstrategies in place driven at
the quality of care and the costof care.
Speaker 4 (05:38):
That's exactly right, rob.
In fact, we've had our MedicareACO since 2016, really focused
on our Medicare patients.
Similarly, our Medicaid ACOlaunched in 2021.
And that is really an alternatepayment model by which we can
better address a patient'squality outcomes and total cost
(05:59):
of care, really by focusing oncare coordination and how we
transition patients through thesystem and, ideally, really care
for them in the outpatientsetting.
Speaker 1 (06:09):
So those ACOs, accountable care organizations
what kind of success have you?
Speaker 4 (06:13):
seen with those.
So in our Medicare ACO we havesaved CMS $54 million since we
started and then similarly withthe Medicaid ACO.
We actually started with asignificant downside arrangement
with Medicaid in 2019.
And through now from 2019, wehave saved the state $7.7
(06:36):
million.
Speaker 2 (06:38):
So what are the key drivers of costs in healthcare
plans at this point?
Speaker 3 (06:42):
You know, the drivers for the cost of anything really
come down to two broadcomponents.
There's the cost to providethat service, whatever it may be
, and then there's the demandfor that service, the usage of
that service, or in healthcare,what we like to say is the
utilization of those services.
That's really important.
When we investigate the cost ofcare and why health care is
(07:03):
expensive, how does that playout?
Well, you think about a patient.
A patient has insurance,whether it's governmental or
employee-sponsored, whatever itmay be.
They're making decisions.
They're making decisions eitheron their own or, preferably
with the advice of a physician,on where they're going to get
care, what care they're going toget and when they're going to
(07:25):
get that care.
Those three pieces right welike to say right care, right
place, right time.
It's really important.
It's not a cliche, because thatwill drive costs of care.
Where I think it's important toinvestigate or consider is what
drives human behavior.
When you look at things likeutilization drives human
(07:46):
behavior.
When you look at things likeutilization, there are employers
who have sponsored health plansthat do not have that
creativity built into theirhealth plans.
There are no incentives ordisincentives for their
population and, as a result,their experiences are higher
cost of care, they have higherutilization, they have a higher
cost trend and ultimately theyhave less healthy employees and
(08:08):
dependents and it's because theyhaven't designed their health
plan accordingly to drive theright results.
You can put design functions inplace so that employees,
consumers of care, will likelysee their primary care physician
, maybe on an annual basis,depending on the features of the
(08:30):
plan.
Maybe they'll have programslike tobacco cessation, for
example.
Maybe there'll be disincentivesthat will essentially pass more
of the cost of an emergencydepartment visit to that plan
participant or that employee,because you don't want somebody
that doesn't need to go to theemergency department to go to
the emergency department.
Speaker 4 (08:48):
With our benefits team here at Christiana Care.
We sat down probably threeyears ago and talked about the
health risk assessments thatmany employers do for their
employees and the fact thatthere's really no evidence to
show that that drives down thecost of care.
What does is connection to aprimary care provider.
(09:09):
It improves screening forhealth conditions and it
improves the total cost of care.
So we actually changed ourbenefit design here at
Christiana Care in order toincentivize that primary care
visit and saw significantlyincreased use of primary care
through doing that and, as aresult, a decrease in our total
(09:30):
cost of care.
Speaker 3 (09:31):
So it absolutely played out here and continues to
so what I hear you saying is,by shaping those, those benefits
, the behaviors we're drivingcare to a lower cost setting,
avoiding a higher cost setting,driving down cost overall.
And I think what I hear youalso saying is we have healthy
people, healthier people as aresult.
Speaker 4 (09:53):
Absolutely.
Speaker 3 (09:54):
So the benefit of that, the overall benefit of
that, is healthier peopleutilizing the right care at a
lower cost, greater productivityout of those healthier people
as well.
Speaker 1 (10:04):
As you're having these internal conversations,
you're also focusing onvalue-based care.
Can you walk us?
Speaker 4 (10:10):
through that Sure.
So value-based care essentiallyis population health.
So how you manage a populationof patients and generally we
think about a population as apopulation under a payer so
Medicaid, medicare or differentcommercial insurance and in that
model there are expectations tomeet quality measures and then
(10:33):
expectations around total costof care.
So if you're able to decreasecost year over year while
maintaining or increasingquality for that population,
there's an opportunity for boththe health provider and the
payer to share in that savingsand ideally that share in the
savings that the payer receivesalso goes on to improve the
(10:57):
dollars back to the employer.
So it helps the affordabilityof that care as well.
Speaker 1 (11:01):
Chris, you are a primary care physician.
How does this improve care forthe patient?
Speaker 4 (11:07):
The way that this improves care is it drives
primary care docs to engageregularly with their patients,
and we talk about not justvisits with patients but the
time between visits whenpatients may have questions, may
have concerns about medication,may have side effects that they
need to talk to a clinicianabout, and what we're really
(11:28):
working on at Christiana Care isbuilding that infrastructure
for the between-visit care,working to build care management
functions through CareVO,working in our practices to set
up digital ways to connect withpatients and work on our triage
process across the medical group.
So all these play into bettercare for patients between those
(11:50):
visits, which ultimately leadsto better chronic disease
management, better cancerscreening, better control of
behavioral health conditions,which also are significant
factors here, but overall leadsto improved health of our
populations we serve leads toimproved health of our
(12:11):
populations we serve.
Speaker 1 (12:11):
So in the national conversation of value based care
, I've heard the term riskassociated with this.
How is it?
Speaker 4 (12:15):
a risk?
Well, it's a risk in the sensethat if you commit to decreasing
the total cost of care and youdon't achieve a decrease, then
that loss, if you will, isshared between the payer and the
provider.
Speaker 2 (12:30):
So we've talked a lot about quality of care and
efficiency and wellness.
Dive a little deeper into that.
What are we doing here,specifically at Christiana Care,
to get further into thiscontrolling of cost?
Speaker 4 (12:41):
So over the last many , many years Christiana has been
focused on our inpatientquality, driving to centers of
excellence in our hospital,working with hospital-acquired
infections, zero harm, and thatwork has been tremendous.
At the same time, we've beenbuilding our capabilities in the
outpatient space to bettermanage patients to keep them out
(13:04):
of the hospital.
Our next horizon is really tobring the two together to think
about how the whole carecontinuum is focused on
population health and that meanslength of stay.
How are we getting patients whodo need to be admitted in the
door the right care as quicklyas possible and have them go
home at a reasonable timeframeand really focusing on
(13:26):
efficiency overall and Project.
Speaker 3 (13:29):
Bedrock Project.
Bedrock is an enterprise-wideproject that is focused on
driving operational performanceright.
So it's across the clinicalspectrum, it's across the
administrative spectrum, allacross the organization, in
really driving down overall costand looking at ways that we can
(13:51):
be more efficient, changingwhat we do, changing how we
think, changing how we workright to become more efficient.
At Christiana Care we launchedthis project about a year and a
half ago.
We've paired up administrativeleaders with clinical leaders
and gone after projects to saywhat can we do differently about
(14:13):
, let's say, efficiencies in anoperating room?
And we have a very formalized,rigid structure to identify what
these opportunities are.
We measure them and then wereport back.
This happens on a weekly basis.
There's other work streams aswell.
One of those is supply chainright.
So we look at ways that we canget better contracts with our
supplier, providers, useproducts more efficiently and so
(14:37):
forth, looking to driveefficiencies to drive down that
cost.
We've realized we have aresponsibility at Christiana
Care to help control that costof health spend.
Even though the hospitals areonly 30%, we are looking broader
, across all of healthcare todrive that down.
Speaker 2 (14:54):
Recently, ChristianaCare was ranked as the
number five health system byMoney Magazine, which is awesome
.
Congratulations.
Money Magazine gaveChristianaCare an A for price
transparency.
What does that mean?
What is price transparency andhow does that benefit the
community?
Speaker 3 (15:09):
And aside from Money Magazine, there is an
independent price transparencyverification provider called
Turquoise.
Turquoise gave us their highestlevel, their highest rating.
We were the first hospital andhealth system in Delaware and in
the region to get that highestrating.
It is about making transparentthe costs for the services we
provide to patients, so thatcould be on a procedure by
(15:32):
procedure or visit by visit,whatever those services are.
We've posted those charges andthen mapped it against the major
insurance providers to say thisis what you can expect to pay
when you come to ChristianaCarefor that service.
At ChristianaCare there's a keyword in our mission and that's
(15:53):
called value, and we want all ofthe people that we serve in all
the communities we serve, tounderstand that value, but it's
the value through their lens.
So we'll give them tools likeposting our charges online to
show that transparency.
And we also offer ability forpatients or members of the
community to give us a call andwe have counselors and other
(16:14):
assistants to help withunderstanding what the costs of
care are, because they arecomplex.
It goes beyond pricetransparency but it really
supports it.
When you look at the ways thatwe bill people, we are looking
at friendly billing options andsome of those are electronic.
So if you go to your doctor atChristiana Care, you can have
(16:37):
the opportunity to have yourbill sent to you via text or an
email.
And what's really interesting inthis, and where I see the value
, is that there's a feedbackloop with this transaction.
So if I'm a patient and I get abill from my doctor, I can pay
it online on my phone, review orprovide feedback about my visit
.
I can provide feedback aboutthe payment.
(16:59):
We had a patient and she usedthis transparent payment system
and provided feedback, and herfeedback was I didn't realize
that I could take advantage of apayment plan for my services.
What really was important andwhat this patient said was I
have trouble paying for my care.
I was going to avoid care.
(17:21):
I was not going to go back tothe doctor because I didn't
think I could afford it, butwith a payment plan, I realized
that I can and I'm going to getthat care.
That's transparency in action.
That is the value oftransparency whether it's on a
website with charges, whetherit's a phone call or whether if
it's the way we can help billpeople and provide that feedback
(17:43):
loop, is really important.
Speaker 4 (17:45):
Rob, that is so important.
I can't tell you how many timesI've had the experience of
having a patient bring in a billfrom an inpatient stay and be
very, very concerned about thecharges.
They're not understanding thiswas in the past and another
health system, but it really hasthe potential to get in the way
of healing for that patientjust having been admitted and
(18:08):
really goes such a long way topromoting their wellness
long-term.
Speaker 1 (18:12):
And Chris, let's dive a little bit deeper into that
your experience in primary care.
Why is this so important, atthe end of the day, for the
average listener right now?
Speaker 4 (18:23):
I went into primary care because I believe in
prevention, I believe inwellness, I believe in keeping
people healthy.
I believe value-based care isthe way we can do this together
because it allows for adifferent payment model that
doesn't incentivize frequenthospital utilization.
In these type of payment models, it incentivizes us building
(18:46):
infrastructure to keep patientshealthier and out of the
hospital.
Speaker 2 (18:50):
This is part of our series of the toughest questions
in health care, and it's notjust about what's happening
right now.
It's, you know, using thecrystal ball to look a little
bit into the future.
So what does the future ofhealthcare costs look like to
each of you?
Speaker 3 (19:04):
I wish I had the crystal ball to tell you, but
what I will say is I amoptimistic about the cost of
care going forward.
We shared some stats earlier.
We talked about that 4%increase year over year.
Hospitals and physicians are atto two and a half percent.
What we are doing is startingto make a difference, as Chris
mentioned a moment ago.
When you talk about value-basedprograms, you talk about the
(19:26):
investments we are making right,whether it's a project bedrock
internally that's focused onefficiencies, or where we are
making investments for places toget care.
What do I mean by that?
We recently announcedneighborhood hospitals that we
are investing in.
So you're talking about a lowercost setting to provide care.
We have partnered with someprivate physicians on ambulatory
(19:50):
surgery centers.
In the area we have three ofthose that takes a surgery that
could be done in a higher costenvironment in an acute care
facility into an ambulatorysurgery center same quality,
lower cost, better experience.
Right Now, there's always areason to have certain surgeries
in the hospital, those that canbe moved out.
(20:10):
We are doing that.
That is less revenue for us asa health system, but we know
it's the right thing for thepatient and it drives down cost.
We are also investing intechnologies.
We're talking about things likehospital at home.
We're talking about things likevirtual nursing, skilled
nursing at home.
Right, these are right care,right place, right time.
This is about getting care in ahome.
(20:31):
It's cheaper, it's betterexperience, it's better in the
long term.
I am highly optimistic andconfident that hospitals will
lead the way in driving costsdown for overall healthcare
spend into the future.
Speaker 4 (20:43):
I totally agree, rob.
I am absolutely optimisticabout the future.
Our strategic plan atChristianaCare is completely
focused on being successful inpopulation health and doing the
things we need to do, making thechanges, population health and
doing the things we need to do,making the changes, making the
commitments we need to propel usforward.
I can tell you that ourclinicians are also very
(21:04):
invigorated by this model,thinking about how to care for
patients in a different and abetter way, and those are the
conversations that we're havingacross the organization and
really just see unlimitedpotential in the future.
Speaker 1 (21:18):
Rob and Chris.
Thank you both so much for yourtime today.
Thank you.
Speaker 2 (21:21):
We'll have more information on the cost of care,
including a link to ChristianaCare's price transparency site
in the show notes atchristianacareorg.
Speaker 1 (21:29):
And while you're there, you can subscribe to For
the Love of Health on ApplePodcasts or Spotify and follow
Christiana Care on social media.
Speaker 2 (21:36):
We'll be back in two weeks with another great
conversation.
Speaker 1 (21:39):
Until then, thanks for joining us for.
Speaker 2 (21:41):
The Love of Health.
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