Healthcare delivery is moving “up and out”


Our graphic this week captures a phenomenon that we’ve observed in our strategy work with regional, “super-regional” and national health systems. We call it the “up and out” phenomenon—healthcare delivery is increasingly being pulled up and out from local, siloed hospitals. The traditional hospital enterprise, operating in what we refer to below as the “fee-for-service zone”, has typically pursued a service approach that delivers all things to all people. Commonly, the combination of reimbursement incentives and health system governance structures has encouraged hospital executives to prioritize facility profitability over system performance.

One important source of value creation for regional systems is service line rationalization—essentially, consolidating key services in one facility rather than performing duplicative services in every hospital. Centralizing open heart surgery, for example, in one “center of excellence” in a region often results in both lower cost and higher quality, thanks to clinical and operational scale economies. But the economies of scale don’t necessarily run out at the regional level—for some high-end specialty services (transplants, for example) it makes sense to consolidate at a super-regional or national level. For a better outcome and lower price, consumers will be increasingly willing to travel to receive the best value care.

Meanwhile, many services currently performed in the hospital can be more efficiently performed in non-hospital settings and should be distributed across the market in ways that are more convenient and accessible for patients. Traditional hospital economics make the “inpatient-to-outpatient shift” problematic, but as price and access become important consumer engagement levers, there’s little use fighting that shift. Indeed, the logical setting for much care delivery is in the patient’s home itself. This puts systems in the position of pushing care delivery to the hyper-local level, a strategy that can be powered by digital medicine delivered at a national level. All of this raises an important question for the regional health system: as hands-on care is increasingly pulled “up” to the national level (centers of excellence) and pushed “out” to the community setting (home-based care), and as national providers of digital health services can deliver services to anywhere, from anywhere, what is the value of the regional system? We’re working with a number of members to better understand and prepare for this new operating model.



The National Academies of Sciences, Engineering, and Medicine has published a detailed report on implementing efforts to address the social needs of patients.


Social needs play a pivotal role in patient outcomes.

Before setting strategies to address social determinants of health, healthcare organizations should assess their level of existing social needs activities.

Partnerships are a crucial component of addressing the social needs of patients.

Healthcare providers can address social determinants of health through five approaches—awareness, adjustment, assistance, alignment, and advocacy, according to a report from the National Academies of Sciences, Engineering, and Medicine.

Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOHs and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.

“The consistent and compelling evidence concerning how social determinants shape health has led to a growing recognition throughout the healthcare sector that improvements in overall health metrics are likely to depend—at least in part—on attention being paid to these social determinants,” the National Academies report says.

The report outlines the “5As” strategies that healthcare organizations can implement to address SDOHs in the communities they serve. The strategies were developed by the National Academies’ Committee on Integrating Social Needs Care into the Delivery of Healthcare to Improve the Nation’s Health, Board on Health Care Services, Health and Medicine Division.


The committee says awareness should focus on identifying the social risks and assets of specific patients and populations of patients.

“On the clinical side, patients visiting healthcare organizations are increasingly being asked to answer social risk screening questions in the context of their care and care planning. In some places, screening is incentivized by payers. As part of the MassHealth Medicaid program, for instance, Massachusetts accountable care organizations now include social screening as a measure of care quality,” the report says.


Instead of addressing social needs directly, healthcare organizations can pursue a strategy that focuses on adjusting clinical care to address social determinants of health.

“Many examples of adjustment strategies were identified in the literature, including the delivery of language- and literacy-concordant services; smaller doctor-patient panel sizes for cases with socially complex needs (e.g., teams caring for homeless patients in the U.S. Department of Veterans Affairs health system have panel sizes smaller than the size of other VA care teams); offering open-access scheduling or evening and weekend clinic access; and providing telehealth services, especially in rural areas,” the report says.


Healthcare organizations can pursue strategies to connect patients with social needs to government and community resources.

“The literature contains descriptions of a variety of assistance activities that have been undertaken by health systems and communities. These assistance activities vary in intensity, from lighter touch (one-time provision of resources, information, or referrals) to longer and more intensive interventions that attempt to assess and address patient-prioritized social needs more comprehensively,” the report says.

Intensive interventions include relationship building, comprehensive biopsychosocial needs assessments, care planning, motivational interviewing, and long-term community-based supports.


Healthcare providers can pursue an alignment strategy that assesses the social care assets in the community, organizes those assets to promote teamwork across organizations, and invests in assets to impact health outcomes.

“The committee defined alignment activities to include those undertaken by healthcare systems to understand existing social care assets in the community, organize them in such a way as to encourage synergy among the various activities, and invest in and deploy them to prevent emerging social needs and improve health outcomes,” the report says.


Healthcare providers can form alliances with social care organizations to advocate for policies that promote the creation and distribution of assets or resources to address social determinants of health. For example, healthcare organizations can call for policy changes to overhaul transportation services in a community.

“In both the alignment and advocacy categories, healthcare organizations leverage their political, social, and economic capital within a community or local environment to encourage and enable healthcare and social care organizations to partner and pool resources, such as services and information, to achieve greater net benefit from the healthcare and social care services available in the community,” the report says.


Assessing the level of existing social needs activities should be a starting point for healthcare organizations that want to address social determinants of health, the chairperson of the National Academies committee told HealthLeaders.

One of the first steps healthcare organizations can take is identifying activities they may already have underway that fit the 5As, then expand or enhance those activities through greater commitment from leadership, investment of resources into supporting infrastructure, and strengthening of engagement with patients and community stakeholders, said Kirsten Bibbins-Domingo, PhD, MD, MAS, professor and chair, Department of Epidemiology and Biostatistics, UCSF School of Medicine, University of California, San Francisco.

“Healthcare organizations may not have activities in all of the 5As and should use this framework to develop strategies that will work within their local context. In all cases, it is critical to be aware that addressing health-related social needs of their patients is essential to achieving goals of high quality and high-value care,” she said.

“Partnerships are crucial,” Bibbins-Domingo said.

“Activities in the clinical setting should be designed and implemented in a way that engages patients, community partners, frontline staff, social care workers, and clinicians in planning and evaluation, as well as in incorporating the preferences of patients and communities. Establishing linkages and communication pathways between healthcare and social service providers is critical, including personal care aides, home care aides, and others who provide care and support for seriously ill and disabled patients.”




Health-care stocks are in their longest losing streak since 2016

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The health-care sector just closed out a third straight month in the red, its longest losing streak in three years.

A fourth monthly decline would be its worst stretch since 2011, and one trader says there could be more pain ahead.

“I view the whole sector as a wounded target right now,” said Boris Schlossberg of BK Asset Management on CNBC’s “Trading Nation” on Monday. “Health care, in my opinion, is the most bloated, the most bureaucratic, the most inefficient sector of the economy. At 20% of the GDP and at $20,000 premium per capita at this point, they pretty much have squeezed all the rentier profits out of the system that they can at this point.”

The sector also has a target on its back as the 2020 presidential election draws closer. The XLV health care ETF has fallen more than 3% in the past three months as Democratic presidential candidates such as Elizabeth Warren have pushed for a “Medicare For All” solution.

“Even if the Democrats do not win, there’s going to be tremendous amount of pressure to cut costs, control drug prices,” said Schlossberg. “Any way you slice it, basically the sector is a ‘sell the rally’ trade at this point. Any time you have a pop in the sector, it’s going to be a sell for quite a long time.”

Health-care stocks faced similar pressure in 2015 and 2016 as Democratic presidential candidate Hillary Clinton pledged health-care reform. At its worst, the XLV ETF plummeted 11% in the third quarter of 2015.

However, Miller Tabak equity strategist Matt Maley does not see that degree of decline this time.

“I don’t think it’ll be anywhere near as bad as it was four years ago because the setup is much, much different. In the 12 months leading into the summer before the election year the last time around, the XLV had outperformed the S&P by two times,” said Maley on “Trading Nation” on Monday. “This group had become very overbought, and very over-owned.”

This time around, Maley says the XLV ETF had performed in line with the S&P 500 before beginning its breakdown in April.

“I don’t think you’ll have that forced selling or at least that reweighting that you had going forward. So even though I think it’s a problem, it’s not as big a problem,” said Maley.








Recession Panic May Have Passed. But the Economy Is Still at Risk

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The underlying forces that fueled worry a few weeks ago haven’t gone anywhere.

For one brief, terrifying moment this summer, the word “recession” was on everyone’s lips — the stuff of television segments, front-page articles and Google searches.

Then, just as abruptly, everything started to look pretty much fine.

The trade war with China went into another of its periodic phases of de-escalation, as the Trump administration seemed rattled about the possibility of a faltering economy. The Federal Reserve cut interest rates twice, something of an insurance policy against a recession. Much of the data on the economy, particularly on the job market and the service sector, remained quite solid.

And the proximate cause of many of those August recession warnings, a sharp drop in longer-term interest rates and a yield curve inversion, was partly reversed.

Crisis averted! That, anyway, has been the mood in financial markets in the last few weeks, as stocks have remained near record highs and the fearful tenor of economic commentary has subsided.

But it would be premature to declare a clean bill of health. Public attention may be focused on an impeachment battle in Washington, but the underlying forces that drove recession fears in the summer are still very much here — with some new ones potentially in play.

The latest, starkest reminder was a new manufacturing number published Tuesday. It showed the sector was contracting in September at its fastest rate since 2009. That might have been dragged down in part by a strike at General Motors, but the softness in the factory sector is evident in other data that predates the strike.

For example, in the last six months, the manufacturing industry in the United States has added an average of only 3,000 jobs a month, down from 25,000 a month as recently as the spring of 2018. (The Labor Department will release the latest employment numbers Friday.)

A less noticed piece of data on Friday showed that manufacturing wasn’t the only pocket of weakness.

Spending on nonresidential construction fell 0.4 percent in August, the latest indication that businesses are not investing in new warehouses, factories and office buildings at the rate they were a few months ago.

There is a tendency to think of the economic angst caused by the trade wars as resembling a light switch — something that President Trump can turn on and off. Some even think of it as a “Trump Put,” referring to a financial contract that insures against big losses. That is, there’s an assumption that the administration will ease trade tensions if they start to affect the stock market or the economy too negatively.

As the last few weeks have shown, there’s some truth to that. The spike in recession fears in August seemed to bring a more conciliatory tone from the Trump administration, even if concrete progress in trade negotiations isn’t really in evidence.

But the $20 trillion United States economy is a slow-moving beast, and just as the trade rift between the world’s two largest economies didn’t cause a major disruption overnight, neither do a few conciliatory comments make everything O.K.

We are only starting to see the delayed economic impact of a series of trade escalations over the summer and of a slowdown in the global economy. It’s starting to show up in hiring and capital-spending plans, as the latest numbers demonstrate.

For some time, close watchers of federal policy have been urging businesses to think of the trade disruptions not as one-off headlines, but as the continuing cost of doing business globally.

“This kind of goes to the advice we’re giving clients, and we’ve been trying to do this for a while, ‘no head-in-sand behavior here,’” said Scott McCandless, trade policy leader at the accounting firm PwC. “Be cleareyed about this. This will probably be around a while.”

There is reason to view the seemingly more optimistic signs being flashed by financial markets with skepticism.

The yield on 10-year Treasury bonds fell to 1.45 percent in early September from 2.07 percent in late July, an uncommonly sharp drop, before rebounding to 1.64 percent Tuesday. The big swings can be chalked up to global capital flows that aren’t necessarily reflective of the economic outlook in the United States.

But that doesn’t mean there is no signal in the noise. Lower long-term rates imply lower growth and inflation in the United States in the years ahead. While the bond markets are becoming more stable, yields are settling at levels consistent with an American economy that is growing more sluggishly than it has the last few years — albeit not at recession level.

Even after sharp drops Tuesday and Wednesday, the S&P 500 has remained not far from its record highs. But the market is often slow to reflect a shifting economic landscape. When the first rumblings of what would become the global financial crisis took place in August 2007, for example, the stock market actually peaked in October; the economy fell into recession that December.

“The lights haven’t gone out on the economic outlook yet, but they are certainly growing very dim,” said Chris Rupkey, chief financial economist of MUFG Union Bank, in a research note.

A recession is certainly not a foregone conclusion, and a period of slow growth still looks more likely than an outright contraction. But just because the recession talk is out of the headlines doesn’t mean all is well.



Critical Steps for a Hospital Turnaround

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Operational changes can improve a hospital’s performance and prospects, but time is of the essence.

The challenges many community hospitals face have become so unrelenting as to threaten long-term financial viability. It’s important that this threat be met with prompt action and operational changes that can improve the immediate situation as well as sustainability. A formal turnaround plan includes analyses and actions, and becomes a roadmap to redirect hospitals and help them stay on track to serve as community resources for years to come.

What prevents some struggling hospitals from getting an earlier start on a turnaround plan?

JK: Leaders from ailing community hospitals sometimes don’t recognize the severity of their problems or that certain indicators call for quick, corrective action. Some common alarm signals that leaders may tune out at first include a downward trend of days cash on hand, shifts in patient volume across the delivery spectrum, medical staff dissatisfaction or defection, and even bond covenant concerns. Recognizing that problems need to be addressed and changes must be made is the first step toward improvement.

Once it’s clear that “business as usual” isn’t working, how does the turnaround process start?

JK: Typically, the process starts with an operational assessment to evaluate strategy, operations, supply chain, revenue cycle and leadership with the aim of reducing costs and increasing revenue—the tried-and-true formula for financial solvency. The analysis includes a review of data and documents, as well as interviews with board, executive and physician leaders. The process reveals any organizational problems or vulnerabilities that aren’t immediately apparent, and it forms the basis for a turnaround plan, including a detailed action plan. An open mind and fresh perspective are important to be able to see options to go beyond operations as they have always been.

What are some of the key areas an operational assessment looks at for potential savings and cost reduction?

JK: Almost every hospital has room to improve staff productivity. Labor is a hospital’s greatest expense, so optimizing productivity by having the right number and mix of staff can make a big impact. Community hospitals that do not have a productivity tool to achieve and maintain the right staffing levels can typically find savings of 15 to 20 percent in salaries and benefits by implementing a tool. In those hospitals where there’s already some productivity monitoring, implementing a more effective tool or improving processes can result in 5 to 10 percent savings. After labor, supply costs are the second highest expense for a hospital, so that’s another key focus area for cost reduction and savings. Industry benchmarks show that many community hospitals have an opportunity to reduce supply costs by as much as 20 percent.

Assessing revenue cycle is also imperative to help identify, monitor and collect every dollar a hospital is due. Gains can be made in this area by renegotiating health plan contracts, streamlining billing for faster payment, auditing medical record coding and reviewing the chargemaster.

Why do the early stages of a turnaround include benchmarking?

JK: Hospitals can potentially identify significant cost-saving opportunities by comparing themselves to hospitals of similar size and volume. Comparing clinical, operational and financial data also identifies areas for improvement and where to allocate time and money for improvement initiatives. For example, a CHC-managed hospital that recently underwent a successful turnaround had discovered through benchmarking that its staff ratios were higher and its benefits were more expensive compared to similar hospitals. This information prompted leaders to take a closer look at the hospital’s situation, and they found it made sense from a sustainability perspective to downsize staff and bring benefit packages to competitive levels. These actions slashed the hospital’s annual expenses by $5.3 million.

To support and sustain a turnaround effort, who needs to be involved?

JK: It’s a collaborative process requiring the participation of the board of trustees, executive leaders, physician leaders, and in many cases an outside management firm to evaluate the situation and develop a specific plan of action. As we discussed, leaders of struggling hospitals usually see the need for improvement but don’t recognize the severity of their situation. Because of that blind spot, it’s often external stakeholders or bondholders who set corrective action in motion by seeking outside assistance.