Home' The Source : Third Quarter 2015 Contents be eliminated without negatively impacting the quality of care.
Major categories of waste include overutilization and variation
in the way hospital procedures are performed. Experts disagree on
whether variation results from clinical decision-making or simply
because certain populations are sicker.
In addressing variation, Manoukian says HCA focuses on stan-
dardizing processes across the organization, which can improve
outcomes by raising the level of care for all patients.
“What we’re attempting to do is to ensure that all of our facil-
ities have an overall process on how to best manage heart failure
patients within their community,” he says.
Manoukian explains that while some facilities offer comprehen-
sive cardiovascular programs complete with board-certified heart
failure and transplantation specialists, other hospitals with general
cardiologists—or those without a cardiologist on staff at all—may
not be as experienced in managing heart failure.
“It’s really about educating practitioners who might
see a heart failure patient,” he says, pointing out that
this also includes primary care providers and emergency
department physicians. “They, too, need to understand
what the continuum of care for heart failure looks like
so they can make rational decisions that lead to superior
clinical outcomes for these often high-risk and chal-
Another source of wasteful spending experts fre-
quently underscore is overutilization, including the
use of more resources and more expensive services and
prescriptions than necessary.
Amy Boutwell, M.D., MPP, founder of Massachusetts-
based Collaborative Healthcare Strategies, says two
tactics can help hospitals reduce avoidable overuti-
lization. The first is to go beyond standard referrals or
discharges to improve transitional care, an area Boutwell
focuses on in her work with the CMS Center for Innovation and
Partnership for Patients.
“That means high-touch, human-delivered transitional care
directly into the next healthcare setting,” she says, pointing out
that traditional approaches don’t go far enough. “The distinguish-
ing feature is not yesterday’s referral. It’s not, ‘I referred you to
X, or I discharged you to the next setting of care.’ It’s that warm
handover, which today looks more like co-management across
The second strategy is to establish complex or integrated care
teams that focus on the whole person rather than just the current
health issue. It’s especially important for at-risk patients caught in
a cycle of multiple hospitalizations.
“The fact that these patients have high rates of admissions,
readmissions and hospital utilization shows that the current
healthcare delivery system is not working for them,” she says.
Boutwell says real progress demands
hospitals account for behavioral health
and social complexity issues, disagreeing
with the American Medical Association’s
efforts to water down readmission pen-
alties for hospitals serving economically
“What they’re saying is that hospitals
should be allowed to have higher read-
mission rates if they serve poor patrons,”
she says, noting that healthcare systems
need to understand that social complexity
is a huge driver of healthcare utilization.
Boutwell adds that while improving
self-care is a worthy goal, the fact remains
that some patients are unable to do a
better job of taking care of themselves,
and thus will always need a navigator or
advocate. She points to patients strug-
gling to pay for basics like rent and food,
many of whom may not have jobs, ve-
hicles or even enough money for bus fare.
“When people are operating on a
survival level, talking to them about self-
enhancement of their healthcare is, from
a behavioral health and social theory
perspective, patently inappropriate.”
While implementing care transition
programs and integrated care teams re-
quires significant effort and resources,
Boutwell says there are some areas where
hospitals can improve without making
sweeping practice changes.
One of those is high-cost imaging such
as CT scans, which account for up to
40 percent of imaging ordered in
emergency departments. Research
shows some physicians order up to
four times more scans than the lowest
Another source of
use of more
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