On Friday, December 5, the Obama/Biden Transition Team opened up an invitation on www.changegov.com (Join the Discussion:Healthcare) for the nation to participate on a discussion focused on the policy and reform efforts that need to be tackled in order to fix our health system.

Whether true reform results from the efforts to build and strengthen strong public support is yet to be seen, but when was the last time we saw the government seek to incorporate such broad perspectives on such a critical topic. While I do not think that the conversation will reveal anything that we didn’t already know, in terms of fundamental pillars of reforming the health system, these types of outreach efforts may actually “humanize” the process and lend voice to the massive up hill climb our nation has in fixing a broken system.

What I find particularly fascinating with this initiative is that Tom Dschle and company recognize the failure points that doomed past healthcare reform initiatives – the lack public mobilization. While Tom Daschle’s blueprint for health has many similarities to the Clinton health reform blueprint from the early 90’s, it may be that his success or failure in winning the battle for a revamped health system may depend on how effectively a national discussion on health occurs and how engaged the public is behind his referendum for change to the health system.

I met with a client recently and we were discussing the marked improvement that they have seen in their wellness program participation since they began using incentives. We discussed the positive wellness culture they have established, the healthier behavior adoption and the increase in preventive claims compared to total claims as a result of their wellness program. During our discussion a topic came up that few organizations consider when implementing an incentive program – the taxation of rewards.

I think my client put it best when they said “the positive benefit that is derived from wellness programs will result in reduced healthcare costs. But even more important is that our participants will have better health. We use incentives to reward participants for making difficult lifestyle changes, and yet the tax issue makes it feel as if we are penalizing them for doing something good.”

Organizations are struggling with the handling of taxation on incentive and reward programs. As a general rule, incentive prizes and awards given to individuals to reward them for certain achievements are taxable as ordinary income regardless of whether the reward is in the form of cash, merchandise of experiential.

This presents a concern to many organizations who feel that it is difficult enough to get individuals to participate in wellness programs and are concerned about the impact taxing may have on on-going engagement. My client feels that the government is too short-sighted on this issue. Organizations are rewarding participants for adopting behaviors that will ultimately lead to increased prevention and have a positive impact on the spiraling costs of healthcare. Yet, upon issuing a reward, organizations are concerned about the goodwill that is lost once they tax an individual on that reward. Often times, an organization will gross up the reward to off-set the tax cost to the participant, but that is much more difficult for health plans to handle when running a wellness incentive program. Something to consider when implementing a wellness incentive program – how will you handle the taxation issue?

“The hugest impact for a company is that by getting people into wellness programs, and making the case for convenience and preventive care, you are increasing productivity and saving time” because people don’t need to leave the work site, says Sue Adams, Intel’s global health and well-being manager.”

In an effort to improve productivity and make health services accessible to individuals, organizations are establishing on-site clinics. In a recent Wall Street Journal article printMode the prevalence of on-site clinics is increasing as organizations extend their efforts in trying to stem rising healthcare costs.

What an opportunity for retail pharmacies to consider as a strategy. Over the past two years we have seen the success of in-store clinics, such as CVS’ Minute Clinic. I would think that large pharmacy chains are in a unique position to offer companies in-store clinic models on their campuses.

The AMA argues that these on-site clinics should augment the use of a primary care physician but the question that deserves serious consideration is why? Why wouldn’t it make sense for an organization to have a full-time physician on-site that can act as the primary care physician for its workforce? Pitney Bowes says that for every $1 it spends on its clinics, it saves $1 in health-care costs and gains an additional $1 in increased productivity. “We believe this will keep you healthier and contain costs. It is a long-term investment in employees,” says Andrew Gold, Pitney Bowes’s executive director, benefits planning.

These types of alternative care models scare primary care physicians in their antiquated cottage industry and it should. In today’s reimbursement environment, physicians need increasing amounts of volume in order to make money. However, most physicians only see patients after an incident has occurred, not before. These on-site clinics promote prevention as well as manage chronic conditions. Often times, on-site work clinics are cheaper and with individuals having so little time, the convenience factor weighs heavily in the clinics’ favor.

Managed Healthcare Executive recently published the attached article regarding key challenges facing health plans in 2009. The primary challenge that health plans will likely facing according to a survey of health plan executives is competing in the marketplace.

I found this article interesting because the strategies that the identified health plans are using to differentiate and improve their competitive position in the marketplace vary dramatically. Particularly interesting to me was CDPHP’s objective of operating off the framework of the medical home model, which originated around coordinated care efforts for children. However, in the past few years it has broadened to include prevention and improving coordinated care. At the center of this framework is the primary care physician acting as the quarterback for better-coordinated care. While in theory it sounds logical, there are some critical challenges facing this model including:
• A shortage of primary care physicians
• Inequitable reimbursement versus specialty physicians
• Technology issues around data exchange and in some instances a total lack of technology at all

Bruce Nash, MD, chief medical officer for CDPHP believes that “A medical home model will promote primary care as a specialty, develop a new compensation system for PCPs, increase access to PCPs, enhance chronic condition care, decrease redundancy of care and increase value to both patients and providers…You can’t have payment reform without practice reform”

While I agree with many of his points, I wonder if he is over simplifying the model. The challenges of increasing capacity and access are very real given the shortage of PCPs in this country. Furthermore, chronic condition care of an aging population has already created backlogs and requires far more time than most physicians have available.

However, out of all of the strategies mentioned, I think that CDPHP is intriguing because it places prevention and active disease management at the front and center of a new way for health plans to engage patients in preventive behaviors.

Note from Mindy: In her third contribution to Rewarding Health, Amy Kramer, Healthcare Sector Strategist at Maritz, addresses the correlation between hospital employee satisfaction and patient satisfaction. At Maritz, Amy provides industry expertise in the areas of healthcare and wellness and works with clients and account teams in addressing business challenges.

Most people think of hospitals as a place to go when you’re sick. Once there, you feel miserable and have strangers taking care of you. It’s a sterile environment with a funny smell. When you’re at a hospital, the only place you want to be is home. Nevertheless, people need hospitals, and there can be much more to the experience than drafty gowns and longing for home. Maritz studies discovered hospitals with happy, satisfied employees who live and breathe the culture of wellness and carry a positive attitude, tend to have satisfied patients and a healthy pocketbook. Hospitals with superior customer service see patients with fewer adverse events, less hospital visits and shorter lengths of stays. Patients are also more likely to return to a hospital with excellent customer service, even if a physician tells them to go somewhere different.

A friend recently told me an interesting story. Her mother had a heart attack. She lived in a rural area and they were forced to take her to a small remote hospital without state–of-the-art equipment or technology. She considered driving a few extra hours to get her mother to the “premium” hospital, but after walking through the doors of the smaller hospital, and experiencing the compassion, care and knowledge of the staff and physicians, my friend was ultimately relieved. Her mother was too. She was very fearful she was going to have a complication, but was reassured by the quality of care at the hospital.

My friend later found out the hospital had earned a “Magnet Status.” From The Healthcare Management Council wiki:
A Magnet hospital is a hospital that delivers excellent patient outcomes, has a high level of employee job satisfaction, and where there is a low turnover rate and appropriate grievance resolution due to the collaboration of data collection and decision-making in patient care delivery through open communication between nurses and other members of the health care team, which attracts the best physicians and specialists as well as high and satisfied patient volumes. Magnet status has been attained by 180 hospitals around the country out of the 4,200 total hospitals.

My friend’s story and the validity of “magnet status” are solid proof that employee satisfaction can equal patient satisfaction. Engaging employees into the culture of hospitals and treating employees well can (and does!) drive revenue.

Note from Mindy: I welcome Amy Kramer, Healthcare Sector Strategist at Maritz, for her second post. With Amy’s 10 years of experience in the healthcare industry, ranging from pharmacy, hospitals, managed care, and pharmaceuticals, Amy’s thoughts are both detailed and contain real-world applications. Enjoy!

We all know nurses and physicians as the direct respondents to our care as patients. Whether we’re in a doctor’s office, or in the hospital, everyone is working on the same side, right? Not in all cases. There’s definite tension between some nurses and doctors. Nurses tend to call on patients’ needs more than the patient’s physician (as much as five times more). Physicians are under-staffed, but the nurse is counted on to be readily available to answer questions, serve the patient, serve the family and communicate back to the doctor. It could be argued in many cases the nurse may know more about the patient than the actual assigned doctor. There is also the new a new trend of “hospitalists,” an on-site doctor assigned to all “in-patients.” The hospitalist completes rounds on behalf of the patient’s actual doctor, who doesn’t see the patient until after discharge. This trend at first seems incredibly convenient, but we’re learning it’s also damaging the patient experience at times. Not all patients want to see a slew of people. They want direct access to their doctor, and when they don’t get it, it’s the frontline nurses generally taking the disgruntled heat.

In order to deliver optimal patient care, nurses and physicians must collaborate. However, more often than not, physicians see a distinct difference in their roles for caring for patients. There’s an apparent level of hierarchy, and nurses tend to receive the short end of the stick. We hear of a lack of respect, recognition and appreciation for each others’ contributions to patient care. Physicians and nurses need to find a balance in their roles and set expectations to make sure each delivers equal and agreed upon care for the patient.

It’s also imperative for physicians to recognize the strengths and skills nurses bring to the healthcare profession. Nurses have a direct impact on patient health outcomes too. Physicians need recognition for their approach to patients, as well as feedback on ways to make the healthcare environment better for everyone.

At the end of the day, both nurses and physicians want the best treatment and care for their patients. To achieve this shared goal, they need to realize they have to work through their differences and appreciate each other’s contributions. When the working environment is better for the people providing the care, patients ultimately win with a better experience and care.

The shortage of healthcare professionals across the healthcare value chain continues to challenge providers. We’re all familiar with the shortage of nurses and the impact it is having on hospital care delivery. A recent study features the shortage of primary care physicians and its impact on potential healthcare reform and the medical home model. And now this article by Modern Medicine discusses the shortage of pharmacists across the country. This is a critical challenge for pharmacies as the retail pharmacy market continues to shift its model and offer an increasing number of health-related services. At the cornerstone of this strategy is the pharmacist.

The combination of an aging population, more chronic-disease patients, a renewed focus on the medical home model, and an increasing number of community-based pharmacy wellness programs, has created an ever-growing reliance on pharmacists. They need to be able to deliver the necessary counseling and patient/consumer interaction to deliver against some of these new expectations, while continuing to maintain their primary responsibility – filling prescriptions correctly.

The issue of health professional shortages will continue to be a roadblock to health reform efforts if we do not find some way to address it relatively quickly.

Note from Mindy: I’m pleased my colleague, Amy Kramer, Healthcare Sector Strategist at Maritz, will contribute her expertise to Rewarding Health with a series of posts focusing on the impact of hospitals and hospital staff on patient wellness and satisfaction. Amy’s role at Maritz is to build strategy and business solutions to help healthcare companies meet business requirements for growth and sustainability. Her posts will be particularly insightful to hospital management, public health officials, wellness managers and anyone who has had an extended hospital stay (or may have one in the future).

In an October post, Mindy touched on the issue of physician shortage, and its impact on our healthcare system. I’d like to discuss another significant shortage trend in healthcare impacting the delivery of quality care and patient wellness – the lack of nurses.

The American Hospital Association reports a 400,000 shortage of nurses by 2010. This is an astonishing gap, especially when you consider the nurse is essentially the full-time caretaker of most inpatients. Nurses interact with patients more than the doctor. They treat the patient, dispense medications and provide a compassionate, comfortable and optimistic environment. Nurses are overworked, under compensated and under appreciated. Combine these factors with intense physical labor and an emotional environment, and you end up with an increasing burnout rate. Adding to the problem, it’s also increasingly difficult to recruit new nurses and retain high-performers.

The end result of the nursing shortage directly impacts the quality of patient care. When employee satisfaction is poor, the quality of care decreases and patient satisfaction suffers. Also, the limited number of nurses means there are a limited amount of resources available to treat patients. Both situations elevate the possibilities for undesirable situations, , such as longer waiting times, care complications and more hospital visits. Ultimately, a nursing shortage negatively impacts the patient experience, one of the key factors in a hospital’s Joint Commission on Accreditation of Healthcare Organizations (JACHO) scores. Lower JACHO scores could cost a hospital millions of dollars.

To help address the nursing shortage, hospitals first need to develop an employee engagement strategy specifically for nurses. The strategy should incorporate recognition, as well as focus on building a stronger culture with better work/life balance. Many hospitals only recently started to consider offering recognition programs to employees. Some even listed recognition as a line item on P and L sheets. This shift towards recognition is a great step to help patch the tainted feelings of nurses. However, much more needs to be done to get the nursing profession back on track. If the nursing shortage improves, expect to see overall wellness and patient satisfaction improve as well.

You can read more about this in a recent Forbes magazine article, which showcases the patient satisfaction issues U.S. hospitals face.