Jim LindstromJournal #1
This summer I am working at NewYork-Presbyterian Hospital (NYPH). At first glance, this seems like a strange place for a social enterprise summer fellow. While many of my peers are in grassroots organizations in far off countries, I am in a strategy office in the wealthiest zip code in Manhattan's upper east side. However, this is one of the best bases for trying to improve health care, both locally and nationally. NYPH is a non-profit and takes seriously its responsibilities to serve the local community. At the same time, it's scale and reputation as a top academic medical center give it a voice at the table in the ongoing national dialogue on health care reform.
Locally, there are significant health care challenges, particularly in northern Manhattan, near Columbia's medical campus at 168th Street. Chronic disease prevalence is drastically higher in this area, and is compounded by poor access to primary care and high rates of uninsured. NYPH has led an initiative focused on this area to help area primary care physicians move to an emerging model of health care called the Patient-Centered Medical Home. The Medical Home model is designed upon the notion that if each person in the community should be assigned to a primary care team charged with maintaining that person's health. This sounds straightforward, but is a radical shift from the status quo which is organized around treating diseases versus maintaining health.
Nationally, my internship has coincided perfectly with a crescendo in the health care reform dialogue. One way that NYPH is trying to play a constructive role in health care reform is by educating legislators and the public. Over the past few weeks, I have been researching other health care models, notably the Dutch health care system. The Dutch system scores similar to the US on quality indicators, but costs roughly half as much per person. The US system is, however, unrivaled in producing medical innovation and is home to the lion's share of the world's top hospitals, and so the challenge is to identify changes that retain top-notch quality but reduce costs.
I encourage everyone to tune into health care reform as it unfolds this summer. The health care system touches everyone at some point in their lives, it eats up one of every six dollars earned in this country, and it is an area in which we as a country have an opportunity to help out those in need in our own back yard.
Journal #2
On my first day at NewYork-Presybterian Hospital (NYPH), I heard someone use the phrase, “No margin, no mission.” This phrase alludes to the tension between impact and sustainability. It affirms that the mission of the hospital is to save lives and improve quality of life, but stresses that if profit margins were to disappear, there wouldn’t be any money to pursue the mission. For smaller non-profits, the availability of philanthropy may mitigate this tension, but at NYPH—which employs almost 20,000 individuals and delivers over $3B of care each year—philanthropy is not sufficient to mitigate unprofitability.
This tension has been interesting to observe through the first part of my internship. For instance, entire departments are in existence that can potentially hurt the financial position of the hospital, but serve the mission. The Patient Services group, for example, calls patients after discharge. Part of their aim is to solicit feedback that will help improve patient satisfaction. However, they also ensure that patients understand their treatment regimens, have been able to fill prescriptions, and know who they can contact if they need further help. The scale of these activities far exceeds what profit-maximization would dictate.
Another point of conflict between mission and margin is the 30-day re-admission rate which is the number of patients who return to the hospital within 30 days. The hospital’s mission obviously includes keeping patients healthy. It is important to note, however, significant cause of these re-admissions is patient non-compliance with treatment (e.g., a patient fails to fill a prescription or stops taking medications early). In order for the hospital to prevent these re-admissions, it needs to interact with patients who have been discharged—something most hospitals have never considered. (Tellingly, the unit of volume in hospitals is typically called “discharges.”)
One project I have been involved with at the hospital is an initiative to do just this. The hospital is building alliances with primary care practices in the community and helping them to establish “medical home” practices. The medical home model is one in which a patient’s primary care physician (PCP) plays a much larger role in coordinating his care. The PCP receives lab workups done at specialists and hospitals, pro-actively checks for preventable events (e.g., the onset of diabetes in obese patients) and monitors the status of patients who are undergoing home treatment (e.g., oral chemotherapy for cancer patients).
My role has been to go out to clinics in the community and help establish relations between the hospital and the physicians. As a representative of the hospital, we are then helping physicians begin the transition towards becoming a medical home by conducting a gap analysis to determine what changes need take place. It has been striking and remarkable to see the differences between this major academic medical center, with state-of-the-art technology and beautifully architected buildings and single-physician offices in impoverished areas of Manhattan. Ironically, these single-physician groups are ahead of the curve in some areas such as IT, because they are nimble and not encumbered by legacy systems installed years ago. What they lack, however, is the expertise with new healthcare delivery systems, which my group is providing. My hope is that as this initiative progresses, the hospital will see its readmissions drop, patients will remain healthier, and these primary care offices in underserved areas will be modernized so that the entire system can better serve the patients.
