As care shifts to community wellness, costs will ease, hospital leader predicts

Pharmacists aren’t the only professionals grappling with the uncertainties of health reform, shifting patient-care delivery models and changing reimbursement standards. Doctors also are trying to redefine their health mission, patient relationships and practice priorities, said Toby Cosgrove, M.D., the top executive at Cleveland Clinic, one of the nation’s premier healthcare organizations.

(For the full chain pharmacy section of DSN's Aug. 25 issue, click here.)



A decade from now, the U.S. healthcare system “is going to be very different,” said Cosgrove, president and CEO of Cleveland Clinic.



“I think ... we’re dealing with probably the biggest social change going on in the United States since the New Deal,” Cosgrove said in a presentation on the future of health care at the “Health for Tomorrow” summit. “It affects 100% of the people and 18% of the GDP. And it’s changing a business that’s gone from B-to-B to B-to-C. So there’s going to be enormous change, and as a profession and an industry, we’re having slow adoption of this, and difficulty moving through it.”



Hampering the medical profession’s embrace of change, Cosgrove said, is the disruption that comes with it. “When we got into medical school, our career was pretty much fixed. Now, it’s very different. We don’t know what we’re going to get paid, what we’re going to get paid for or where we’re going to practice,” he said. “And we don’t know what kind of medicine we’re going to be practicing.”



“We’re going through a very interesting period,” Cosgrove said. “It’s a tough transition.”



Even well before the onset of the Affordable Care Act and health reform, mounting cost concerns were driving big changes in U.S. healthcare delivery, he said. “Twenty years ago, there were a million hospital beds in the United States. Now there are 800,000, and it’s 65% occupancy,” Cosgrove said. “You’re going to see a consolidation, a closure of hospitals and a reduction in hospital beds as more and more things move out of the hospital.”



Where have those patients gone? For one thing, they’re shifting to outpatient care sites like clinics and pharmacies staffed by clinically oriented pharmacists who can deal with patients with chronic conditions. They’re also being transferred out of the hospital and into the community care setting and their own homes much more quickly following most surgeries, Cosgrove said. Nowadays, “people don’t get hospitalized for chronic disease until they reach desperate straits; that’s taken care of by outpatient [settings].”



What’s more, he added, many surgeries like knee reconstruction, mastectomies and thyroidectomies are now being done on almost an outpatient basis, involving just one- or two-night stays.



“That is going to decrease demand for hospitals,” he said.



Cosgrove was joined onstage by physician and New York Times senior writer Elisabeth Rosenthal, who posed a question that was never far from the surface at the daylong summit. Given that drop in demand, she asked Cosgrove, “as we close hospitals and move patients to an outpatient setting, why aren’t there more cost savings?”



One big reason, Cosgrove said, is cost shifting. As health systems lowered prices on procedures within their hospitals to compete more effectively for insurer reimbursements, they raised prices for outpatient care. “The costs just got moved from one place to another,” he said.



Cosgrove offered some solutions to this ever-rising cost spiral. “We recognize we have too costly a healthcare delivery system. There are only two ways we can take costs out of it. One is by having a more efficient delivery system. And the second is by having less disease ... if we kept people healthy.”



To that end, Cleveland Clinic adopted a sweeping set of initiatives aimed at making its own 43,000 employees healthier. “We started by taking steps to try to prevent disease,” he said, by addressing “smoking, lack of exercise and obesity or food intake.”



The health system, which is Cleveland’s largest employer, began by adopting a no-smoking policy on its own campuses, and by offering free smoking-cessation programs and nicotine patches not only to its own employees, but also to all residents of Cuyahoga County. “Then we took a bold step; we said we’re not going to hire smokers anymore.”



In addition, Cleveland Clinic pushed the Ohio Board of Regents to ban smoking from all public universities in the state. The result was a reduction in smoking in Cuyahoga County over a five-year period, from 27% of residents to 15%. “And the incidence of smoking among employees of Cleveland Clinic is [now] 6%,” Cosgrove said.



The clinic also overhauled the menus in its own cafeterias, removing unhealthy offerings and even candy machines. It also began offering all employees free access to its on-campus fitness centers, as well as free pedometers and weight-reduction programs. “Over the last five years, we’ve [collectively] lost 450,000 lbs.,” Cosgrove said.



The clinic also began providing its employees with financial incentives to enter into disease management programs for such conditions as diabetes, hypertension, smoking, obesity and asthma.



“We saw a reduction in hospitalizations [for some of those conditions] of 20%,” Cosgrove said.



Another challenge to capping health costs and improving Americans’ health, however, is the lack of continuity in insurance coverage and care. As patients move around and frequently switch insurance plans, “no one [is] investing in [patients’] long-term disease state,” Rosenthal said.



Dealing effectively with that challenge, Cosgrove said, “is a societal issue” that “is going require educators, physicians, universities, government, food producers, food servers — all beginning to realize that it’s in their best interest to deal with this issue. It’s going to take a big national discussion.”



He predicted that the health system would undergo “the disintermediation of hospitals,” adding, “I think you’re going to see lab tests going to Walmart or Walgreens and radiology leaving the hospital. It’s going to be like a department store, and that will increase the efficiency and decrease the costs.” And price, he said, will drive many choices in sites of care.



Health care, in short, is evolving into “a consumer-driven organization ... with transparency around costs” that’s driving a more competitive and efficient health system, Cosgrove said.