Is this a fair representation of the hospital business model?

I have been looking for a way to represent pictorially the hospital business model and the forces which act upon it.  The picture below came to me last night while playing this board game with my daughter.  It is from the children’s game, Boobytrap.  The way the game is played is that the players try to remove the red, blue, and green pieces without causing the trap to spring and displace all of the pieces.

If we represent patients as the individual playing pieces and make the assumption that each side of the game exerts pressure on the model, I think it represents fairly the external forces with which the large provider model has to battle.  As the forces increase from some combination of costs, regulation, procedure price ceilings, and payor reimbursements, the number of patients in the model will decrease and may do so in a catastrophic manner.  Without a concurrent decrease in those four forces it is unlikely that the model will support additional patients.  Clearly, without changing the size of the board it is impossible to grow the number of patients beyond the board’s capacity.

A couple rules come into play.

  • The forces are all external.  They cannot be controlled or abated by the hospital.
  • The strengths of the various forces change over time
  • The forces result in some maximum number of patients which can be serviced under the hospital’s existing business model.
  • As each patient is lost, the stability of the model weakens.

Does this way of depicting the large provider business model ring true?  Does this help illustrate why the model must change?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Herman Melville’s take on healthcare’s business strategy

Someone once summed up one of Fred Astaire’s screen tests with the following; “Can’t sing.  Can’t act.  Balding.  Can dance a little.”  Probably the same guy who evaluated my Mensa application.  I’ve been accused of having a similar outlook.  I once accosted a guy who was walking on water, accusing him of not being able to swim—but that was a looonnngggg time ago.

The internet is full of opinions, but hopefully not full enough. One of the reasons I chose math over English as my major was the affection I held for getting the right answer, or barring that being able to know precisely where my errant efforts led me away from the answer.

In my narrow-minded view of the universe the downside of English, literature—the soft studies—was the notion held by those who taught that there was more to be divined by the story than just the story.  Those who can do; those who can’t teach.  They displayed a Stepford mentality in their obdurate ability to outthink both the author and their students, to bring forth nascent ideas of the author’s hidden meaning.

Herman Melville wrote Moby Dick.  I am willing to bet he wrote it just the way he intended to.  Nobody has uncovered a frayed notebook of Melville having penned his thoughts about the real meaning of life from a cannibal’s perspective, or suggesting Queequeg was a misunderstood cross-dressing sycophant who was never close to his mother.  We don’t come away from our reading of Moby Dick  with a more in-depth ability to understand anything except for perhaps what it felt like to live aboard a whaling ship.

These interpretations are poppycock.  Art critics do the same thing as they bloviate about the hidden meaning behind what the artist really intended to convey, meaning only they can see.  Ever notice how none of these popinjays, these opiners present their opinions as fact?  Pretentious fops.

I write and paint.  Those who’ve read my missives know there is no buried meaning.  If I had wanted to convey something else I would have written something else.  If I use dark colors and bold brush strokes when I paint it is because I feel they add to what I want to show; it is not a reflection of having missed two days of Zoloft.

Nobody will ever know what Shakespeare intended to convey with his addition of the three witches in Macbeth, or whether Joyce Kilmer had ever seen a tree.  That said, I do have a few strong opinions about where this whole business model of healthcare is headed.  I think these types of opinions; along with the opposite opinions differ from the type offered up as truths in an English Lit class.  They differ in that at some point they will be proven right or wrong—time will tell.

As I have written, I think the large provider model—the business model—is seriously flawed.  Moreover, I think it may prove fatal.  Providers will run out of costs to cut, will run out of processes to re-engineer, and will have no more Italian marble with which to line the foyer.  The good news is that they will still have the machine that goes “Ping” just in case somebody needs it.

I do wonder how Melville would have expressed his ideas about healthcare.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Revising your work flows?

revised work flowAs a parent I’ve learned there are two types of tasks–those my children won’t do the first time I ask them, and those they won’t do no matter how many times I ask them.  Here’s the segue.

Let’s agree for the moment that workflows can be parsed into two groups—Easily Repeatable Processes (ERPs) and Barely Repeatable Processes (BRPs). (I read about this concept online via Sigurd Rinde.)

An example of an ERP industry is manufacturing. Healthcare, in many respects, is a BRP industry. BRPs are characterized by collaborative events, exception handling, ad-hoc activities, extensive loss of information, little knowledge acquired and reused, and untrustworthy processes. They involve unplanned events, knowledge work, and creative work.

ERPs are the easy ones to map, model, and structure. They are perfect for large enterprise software vendors like Oracle and SAP whose products include offerings like ERP, SCM, PLM, SRM, CRM.

How can you tell what type of process you are trying to incorporate in your EHR? Here’s one way. If the person standing next to you at Starbucks could watch you work and accurately describe the process, it’s probably an ERP.

So, why discuss ERP and BRP in the same sentence with EHR? The reason is simple. The taxonomy of most, if not all EHR systems, is that they are designed to support an ERP business model. Healthcare providers are faced with the quintessential square peg in a round hole conundrum; trying to get BRPs into an ERP type system. Since much of the ROI in the EHR comes from being able to redesign the workflows, I think either the “R” will be sacrificed, or the “I” will be much higher than planned.

What do you think?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Is your mission statement web site parsley?

What is your organization’s mission, your vision, your goal?  Can you articulate it?  If yes, write it below in the space provided.

Okay.  Why do you have a mission statement?  Is its purpose merely website parsley, or is it actionable?  What does it tell you to do?  Is it something to which all of your employees can contribute?  Can you measure if your actions helped meet the mission?  Does the business strategy result from the mission statement?

Here’s one you probably haven’t thought of.  Let’s say every one of your employees puts your mission statement into action.  Does that improve your organization, or does it bring it to its knees?  Your mission statement either communicates your mission or it does not.  What does it say to your employees, to your customers?  If it does not create a message that makes you unique, fix it or dump it—or say, “We are just like those other guys down the street.”  Just because it communicates, does not make your mission sustainable.

Here are some real examples of hospital mission/vision statements.  Read them and see if you begin to understand why I think the hospital business model is in trouble.  I have not published the name of the hospital, as that is not what is important to this discussion.

Providing exemplary physical, emotional and spiritual care for each of our patients and their families

Balancing the continued commitment to the care of the poor and those most in need with the provision of highly specialized services to a broader community

Building a work environment where each person is valued, respected and has an opportunity for personal and professional growth

Advancing excellence in health services education

Fostering a culture of discovery in all of our activities and supporting exemplary health sciences research

Strengthening our relationships with universities, colleges, other hospitals, agencies and our community

Provide quality health services and facilities for the community, to promote wellness, to relieve suffering, and to restore health as swiftly, safely, and humanely as it can be done, consistent with the best service we can give at the highest value for all concerned

To participate in the creation of healthier lives within the community. * To provide healthcare services in a fiscally responsible manner which contribute to the physical, psychological, social and spiritual well being of the patients and community which it serves. * To provide assistance to the whole person in a Catholic spirit of equality and interfaith serving all regardless of age, color, creed or gender.

We are caring people operating an extraordinary community hospital.

Ensure access to superior quality integrated health care for our community and expand access for underserved populations within the community. Create a supportive team environment for patients, employees, and clinical staff.

Let’s look at some of the million dollar words in the mission statements of some highly regarded hospitals.  Ensure, foster, promote, participate, create.  Comprehensive.  Involved, responsive, collaborate, enable, facilitate, passion, best, unparalleled, .  These statements were written by well paid adults.  These statements are awful.  They are awful because they are fluff—unachievable.  They are well intentioned but meaningless euphemisms.

Here’s my attempt at writing a concise mission statement based on the business models I’ve seen.  We will buy every piece of technology and hire any specialist so we can treat any problem.

Hospital mission statements are very inclusive.  They also seem very similar.  If a perspective patient read your mission statement and read the mission statement of the hospital down the street, could they tell which one is yours?  Probably not.  Who among you has a mission statement which excludes anything?

So, let’s say your board is debating if you should buy the machine in Monty Python’s hospital skit—the machine that goes “Ping.”  Which of the mission’s goals does that support?

How do you make them better?  For starters, make them short. Very.  One writer wrote, “If I had more time, I would have written less.

Southwest Airline’s mission statement—be the low cost carrier.

Dramatic pause.  Something either contributes to the mission or it does not.  Leather seats and free lunches do not.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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Are hospitals causing themselves to go broke?

In our prior home we built a magnificent 1,600 bottle mahogany wine cellar with an in-laid brick floor, a nine-foot high antique door, a cigar humidor, and a tasting table.  We discovered that hexagonally shaped ceramic chimney flue pipes were the perfect building material.  They stacked like honeycomb and helped keep the wine chilled.

Our idea was to enjoy the wines we had collected over time.  There is a trick to being a successful wine collector—one must collect more wines than one consumes.  The principle of buying three and drinking four made our cellar always look brand new—empty.

The same principle applies to business strategy.  One must ensure that inputs exceed outputs, that cash in exceeds cash out.  Wax on—wax off.

If service “A” sells for a hundred dollars and it costs eighty dollars to deliver, that is a sustainable model.  You get to pocket twenty dollars.

If service “B” costs a million dollars a year to be able to offer the service and you can only charge eighty thousand dollars per patient, and fewer than twelve patients require the service, that model is not sustainable.

What happens next?  You have to start borrowing money from somewhere.  Often it comes from those twenty dollars you pocketed from the other services.  Then what happens?  Each time you take the profits away from service “A” to underwrite service “B” you have made both services unsustainable.

Cross-pollinate this concept across a five hundred bed hospital, a hospital whose model already requires it to offer “loss leader” services like caring for the indigent and ER and you can see the model has problems.  It may be possible to keep the model on life support by charging eight dollars for each Tylenol, but sooner or later that model will fail.

While we are at it, let’s look at what happens to service “A”.  The hospital stops performing “A” because they no longer find it profitable.  Then what?  Service “A” gets picked up by a clinic who can deliver it at a cost of forty dollars instead of the eighty it cost the hospital.

It is never the service that is the problem, it is the business model behind the service.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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