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November 2011

Cost Containment: Overcoming Challenges

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NoveMber 2011 | Cost Containment: Overcoming Challenges

page 3

WWW.HEALTHLEADERSMEDIA.COM/INTELLIGENCE | ©2011 HealthLeaders Media, a division of HCPro, Inc.

Foreword

Leaders seek Next strategic LeveL of reveNue cycLe

Healthcare organizations have spent the past 10 years developing robust financial decision-support information and

tools to assist with performance improvement projects. Less energy was spent on developing comparable clinical

information. Now, organizations are beginning to place more emphasis on developing robust clinical data that will

need to be integrated with financial information. This integrated data will be a necessity if the organizations are to

meet the objectives of achieving improved clinical outcomes and standardized and efficient clinical operations.

Business intelligence systems and advanced analytical tools will be needed to achieve these lofty clinical efficiencies.

But most healthcare organizations do not believe we as an industry are close to having robust and integrated data

and tools.

HealthLeaders Media’s annual cost-containment survey shows that the revenue cycle is regarded as the top choice

(30%) of leaders seeking the greatest return in efficiency and cost reduction. That area can provide the highest yields

in efficiencies and cost reduction. But revenue cycle is very general as a priority. Significant numbers of healthcare

organizations are taking their revenue cycle operations to the next strategic level. At CHI we have seen significant

improvement in revenue cycle over the past 10 years, and we are undergoing an extensive diagnostic review of our

revenue cycle operations to identify the next strategic opportunities.

The survey identifies three other key areas of focus in which healthcare provider organizations must be more efficient

and cost effective: purchasing/supply chain; clinical operations, skilled and technical staff; and administrative and

overhead areas.

Past activities in supply chain were mostly concentrated in enhanced supply chain operations and GPO contract

compliance. The next level of improvements will need to be at a strategic level and will need to become more

integrated with clinical operations as the industry does more work with clinical preference and standardization

guidelines. Revised supply distribution models will see enhanced attention in the next three to five years. CHI is about

to begin an extensive diagnostic review of all supply chain operations to identify strategic opportunities.

Healthcare organizations have not put as much focus on clinical operations and outcomes over the past 10 years as

will be required as the industry prepares for lower reimbursement from all payers and transitions to pay based on

http://www.healthleadersmedia.com/INTELLIGENCE/


page 4


clinical outcomes. The need for better operating precision means healthcare organizations will emphasize operational

throughput and efficiency while enhancing clinical outcomes. These types of projects will be more complex than

previous administrative efficiency projects. Additionally, these projects will require better coordination and integration

of clinical, operational, and financial resources.

Healthcare organizations are beginning to plan for a performance improvement cycle that will be more significant

than any we have faced. Most experts believe that efficiency gains of as much as 20% may be needed. Many are

referring to this cycle as the “Medicare Profitability Project.” The magnitude and comprehensive nature of Medicare

profitability projects will be needed to address potentially significant reimbursement cuts from all payers as a result

of healthcare reform.

Dean Swindle

Executive vice president and CFO

Catholic Health Initiatives

Englewood, CO

Lead Advisor for this Intelligence Report



page 5


Table of Contents

Foreword 3

Methodology 6

RespondentProfile 7

Analysis 8

SurveyResults 13

Operations Area With Greatest Return in Efficiency Improvement or Cost Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Difficulty of Achieving Results in Improved Efficiency and Cost Reduction by Clinical Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Use of Information Technology to Guide Cost Efficiency Programs . . 14

Most Critical Need for Performance Data Measurement. . . . . . . . . . . . 14

Staff Resources Dedicated to Cost Reduction and Efficiency . . . . . . . . 15

Efficiency Techniques or Systems Currently in Use . . . . . . . . . . . . . . . . . 15

Critical Functions Outsourced. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Year-Over-Year Direct Savings for Outsourced Functions . . . . . . . . . . . 16

Average Annual Savings From Cost Reduction Programs . . . . . . . . . . . .17

Additional Cost to Pull out of Operating Budget . . . . . . . . . . . . . . . . . . . .17

Biggest Obstacle to Cost Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Cost Reduction Initiative Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Main Cause of Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Method of Sharing Cost Savings Among Stakeholders . . . . . . . . . . . . . 19

Areas of Performance Affected by Programs That Eliminate Waste and Reduce Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20



page 6


Methodology

The 2011 Cost Containment Survey was conducted by the HealthLeaders Media Intelligence Unit, powered

by the HealthLeaders Media Council. It is part of a monthly series of Thought Leadership studies. In August

2011, an online survey was sent to the HealthLeaders Media Council and select members of the HealthLeaders

Media audience. Respondents work in hospital, health system, or physician organization settings. A total of 250

completed surveys are included in the analysis. The margin of error for a sample size of 250 is +/- 6.2% at the

95% confidence interval.

About The HealthLeaders Media Intelligence UnitThe HealthLeaders Media Intelligence Unit, a division of HealthLeaders Media, is the premier source for executive healthcare business research. It provides analysis and forecasts through digital platforms, printed publications, custom reports, white papers, conferences, roundtables, peer networking opportunities, and presentations for senior management.

Intelligence Report Editor philip betbeze [email protected]

PublisherMAttheW [email protected]

Editorial Director eDWARD pReWitt [email protected]

Managing Editor bOb WeRtz [email protected]

Intelligence Unit Director ANN MACKAY [email protected]

Senior Director of Sales Northeast/Western Regional Sales Manager pAUl MAttiOli [email protected]

Media Sales Operations Manager AleX MUlleN [email protected]

Copyright ©2011 healthleaders Media, 5115 Maryland Way, Brentwood, TN 37027 • Opinions expressed are not necessarily those of healthleaders Media. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

Upcoming Intelligence

Report TopicsReform Readiness

Mergers & Acquisitions

2012 Industry Survey

advisors for this iNteLLigeNce reportThe following healthcare leaders graciously provided guidance and insight in the creation of this report.

Jeffrey limbocker CFOOur Lady of the Lake Regional Medical Centerbaton Rouge, lA

paul Kronenberg, MDCEOCrouse HospitalSyracuse, NY

Charles e. hart, MDPresident and CEORegional Health, Inc.Rapid City, SD



Click to Join Now

Dean SwindleEVP and CFOCatholic Health InitiativesEnglewood, CO




page 7


Respondent profile

Respondents represent titles from across the various functional areas including senior leaders, clinical leaders, operations leaders,

finance leaders, and information leaders. More than 40% of the respondents have senior leader titles. They are from hospitals,

health systems, and physician organizations.

| title

0

10

20

30

40

50

7%Finance leaders

2% Information leaders

31% Clinical leaders

19% Operations leaders

41%Senior leaders

Senior Leaders | Administrator, Chief Executive Officer, Chief Financial Officer, Chief Information Officer, Chief Medical Officer, Chief of Staff, Chief Operations Officer, Executive Dir., Partner, Board Member, President, Principal Owner

Clinical Leaders | Chief of Cardiology, Chief of Neurology, Chief of Oncology, Chief of Orthopedics, Chief of Radiology, Chief Nursing Officer, Dir. of Ambulatory Services, Dir. of Clinical Services, Dir. of Emergency Services, Dir. of Inpatient Services, Dir. of Intensive Care Services, Dir. of Nursing, Dir. of Rehabilitation Services, Service Line Director, Dir. of Surgical/Perioperative Services, Medical Director, VP Clinical Informatics, VP Clinical Quality, VP Clinical Services, VP Medical Affairs (Physician Mgmt/MD), VP Nursing

Operations Leaders | Chief Compliance Officer, Chief Purchasing Officer, Asst. Administrator, Chief Counsel, Dir. of Patient Safety, Dir. of Purchasing, Dir. of Quality, Dir. of Safety, VP/Dir. Compliance, VP/Dir. Human Resources, VP/Dir. Operations/Administration, Other VP

Finance Leaders | VP/Dir. Finance, HIM Director, Director of Case Management, Director of Patient Financial Services, Director of RAC, Director of Reimbursement, Director of Revenue Cycle

Information Leaders | Chief Medical Information Officer, Chief Technology Officer, VP/Dir. Technology/MIS/IT

base = 250

base = 142 (hospitals)

| Number of beds

1–50 20%

51–199 32%

200–499 34%

500–999 12%

1,000+ 2%

| type of Organization

base = 250

| Number of Sites

1–5 23%

6–20 29%

21–49 23%

50+ 25%

base = 75 (health systems)

Hospital 57%

Health system 30%

Physician organization 13%

base = 33 (physician orgs)

| Number of physicians

1–2 3%

3–9 12%

10–25 27%

26–49 24%

50–99 15%

100+ 18%



page 8


Generally, as services and retail products get broader distribution, as competition kicks in and as

those services get democratized, they get cheaper. Healthcare doesn’t follow those rules. It gets

more expensive every year—and usually outpaces the rate of inflation, salaries, and everything

else. That clearly can’t continue ad infinitum.

The challenge of cutting costs

under one reimbursement system

while preparing for the advent of

another adds a degree of complexity

as well. That’s reflected in our

annual cost containment survey,

where eliminating excess cost and

waste is seen as a top priority but

where progress is seen as difficult

to achieve. In what areas is it most

challenging? Surgery and the

emergency department top the list,

where 48% and 65%, respectively, say

it is very or moderately difficult.

What makes the ED so difficult? “So

many things are out of your control,”

says Dean Swindle, executive vice

president and CFO at Catholic

Health Initiatives in Englewood, CO,

and the lead advisor for this report.

“Patients show up randomly and

severity is random. You have pretty

good information on some trends,

but you’re limited on what you can

and cannot do. The physician piece

Cost Containment Often Falters on Complexity By Philip Betbeze

What Healthcare Leaders Are Saying

“Operating room information management technology is one of few areas in

the hospital that stands to benefit substantially from a financial standpoint

with a solid return on investment in IT. Unlike other areas of the hospital,

the operating room is most akin to a factory production line, and has the

most to gain from IT implementation.”

—Chief of staff for a small hospital

“Physician program leaders have not been held accountable for cost/

efficiency outcomes, but have significant impact on costs. They are still

operating under the assumption that good quality costs more.”

—VP, director of operations for a midsize hospital

“Most of our leaders believe we have a cost problem, but they believe it

is either someone else’s responsibility to solve this problem, or there is no

solution. We need to move to collective accountability.”

—CFO for a midsize hospital

“We, like many other healthcare organizations, have not developed a way

to break down services into actual costs. Examples include breakdowns

for specific components of nursing care, food service, room cleaning, etc.”

—VP of nursing for a health system

“We can’t get beyond the idea stage. We run around like Chicken Little—the

sky is falling—must reduce costs now. Then, we get absorbed into the next

crisis and forget all about cost reduction. We need to appoint a leader, cre-

ate a plan with measureable goals, get buy-in, implement, and then monitor,

and reassess. We’re just too busy some days to reduce costs.”

—CFO for a physician organization

“Our most successful cost efforts are typically very targeted, which means

we have not been able to take advantage of any kind of hospitalwide effort.”

—CEO for a small hospital

AnAlySiS



page 9


is also tough, because you generally have to outsource

that directly and they have profit margins so you have less

control over your costs.”

Why else doesn’t healthcare follow the rules? For one,

the relationship between the patient (the end user) and

the healthcare entity (the producer) is muddled by the

presence of regulatory and payer bodies. A Byzantine

reimbursement system prevents—or at least discourages—

the type of competition and quality improvement

techniques that define so many other industries. But

that landscape is rapidly changing. It doesn’t mean that healthcare will get less complex—in fact

probably the opposite—but various changes in the way healthcare is evaluated and paid for are

causing healthcare senior leaders to focus as never before on cost control.

In a future that seems dominated by declining reimbursements and clouded by uncertainty,

costs are one area that healthcare leaders feel can be attacked with zeal. However, in many cases it

seems as though healthcare is still going through the experimental stage in this endeavor.

While senior leaders in the survey reported that programs that eliminate waste and reduce cost

had a positive or neutral effect on clinical outcomes and patient satisfaction—by an astounding

96% and 90% respectively—more than 30% listed “reducing cost while also maintaining service

and outcomes” as their biggest obstacle to successful cost reduction.

What gives?

Part of the problem lies in the fact that hospitals must continue to operate—and operate

profitably—in the fee-for-service world, which does essentially nothing to incent healthcare

providers to reduce costs other than through the blunt tool of cutting reimbursements across

the board. For at least a few more years, fee-for-service will continue to be the dominant payment

model. At the same time, leaders must tool up for a reimbursement environment that includes

incentives for lower costs.

AnAlySiS (continued)

“The schizophrenic reimbursement environment makes this extremely difficult.”

—Charles Hart, MD, CEO, Regional Health Inc.,

Rapid City, SD



page 10


“The schizophrenic reimbursement

environment makes this extremely difficult,”

says Charles Hart, MD, CEO of Regional

Health Inc., a system of five hospitals and an

assortment of clinics, nursing homes, and

assisted living facilities in Rapid City, SD.

In adjusting to a different reimbursement

environment, “I feel like I know where we need

to go, but getting there is so difficult,” he says.

“It takes your labor productivity standards and

blows them up because you have to put extra

resources in.”

He’s not alone. Throughput and efficiency are

the top choice of senior leaders (at 32%) when

asked which performance data measurement

area represents their biggest need. Much

of the waste exists there—not to mention problems with coordinating care, which will be a

big factor under future reimbursement schemes. With an eye toward those future schemes,

clinical outcomes (26%) and actual labor productivity (18%) are top priorities for data on which

managers—and physicians—can act.

“The clinical data that many of us use is chart reviews,” says Jeffrey Limbocker, CFO at Our Lady

of the Lake Regional Medical Center in Baton Rouge, LA. “But what you do want to do is be able

to compare high quality outcomes with financial outcomes to determine whether actions taken

to improve clinical quality or reduce cost are having a positive or negative impact on the other.”

Maybe healthcare gets a bad rap in cost containment. Although it’s relatively new to the sector,

most organizations are paying attention to it—to what level is debatable. Yet they do report

significant results, although those results are incremental. Some 70% of respondents said their

average annual savings over the past three years in cost reduction programs have ranged between

1%–5%, while 29% of respondents reported even bigger gains.


“What you do want to do is be able

to compare high quality outcomes

with financial outcomes to determine

whether actions taken to improve

clinical quality or reduce cost are having

a positive or negative impact on the

other.”

—Jeffrey Limbocker, CFO, Our Lady of the Lake Regional Medical Center,

Baton Rouge, LA



page 11


The savings will have to get bigger, says Swindle,

who envisions that over a seven- to 10-year period

CHI will need to achieve 20% improvement in its

operating budget. “Two-thirds of that will come

from operating efficiencies and better effectiveness.

As we work on Medicare profitability, we’ll pick

something like revenue cycle and, over a five-year

period, we’ll work on a 20% reduction in cost to

collect and collect 20% more cash. To effect that

kind of change, the structure can’t look like it looks

today.”

The programs organizations will use will run the

gamut. Yes, some do involve easy (and perhaps

shortsighted) efforts that involve cutting staffing

and other labor costs, but others are innovative

and take advantage of the largely untapped scale

of many hospitals and systems and their formal

relationships to each other. For example, with its GPO, Regional Health recently developed the

Northern Plains Premier Collaborative, a purchasing partnership with a geographically close

partner that pools purchasing power for 40–50 hospitals, Hart says.

“We began to put value analysis teams together to work on group purchase items, and it has

been so successful over the past three years,” he says.

From the simple to the complex, the collaborative standardized gloves throughout all the

hospitals, which saved Regional Health about $250,000 over the time period. “Where we see

the biggest change is in capital purchases where we will spend about $110 million among the

organizations next year,” he says. “You save 2%, 3%, 4% on those things. We bought CT and MRI

scanners together and we saved $30,000 per machine.”


“As we work on Medicare profitability, we’ll pick something like revenue cycle and, over a five-year period, we’ll work on a 20% reduction in cost to collect and collect 20% more cash. To effect that kind of change, the structure can’t look like it looks today.”

—Dean Swindle, executive vice president and CFO, Catholic Health

Initiatives, Englewood, CO



page 12


Yet those kinds of wins might be a little more difficult for smaller players. Perhaps that’s why

nearly half (49%) of survey respondents told us they still have more than 6% to trim from their

operating budgets. Another 49% saw their targets as less than 6%, while 2% feel like they’ve

already achieved the savings they will need.

Because of expected reimbursement declines, it’s critical that not all of the savings from cost

containment programs be plowed back into other spending. That said, perhaps better buy-in

might be obtained if organizations involved in cost-cutting programs were inclined to share

some of the gains. Some 48% of respondents do not share savings at all among stakeholders,

while 30% say the direct benefit accrues at the facility level. Only 19% either use some of the

savings for implementing a bonus structure for participants or use a percentage of the savings

for discretionary reinvestment in that department.

One interesting area that deserves attention is, despite the fact that a large majority of healthcare

leaders say programs that eliminate waste and reduce cost either do not affect or improve clinical

outcomes and patient satisfaction, employee satisfaction often does take a hit, with 37% of

respondents saying the metric declines under the influence of such programs.

Perhaps a little sugar, in the form of sharing the savings, would help the medicine go down a

little easier.

Philip Betbeze is senior leadership editor for HealthLeaders Media.




page 13


Very difficult

1 2 3 4

Not at all difficult

5

Emergency department 30% 35% 23% 10% 1%

Surgery 19% 29% 30% 19% 3%

Inpatient/med-surg/critical care 13% 37% 33% 14% 2%

Imaging 8% 20% 39% 28% 6%

Pharmacy 6% 25% 34% 28% 8%

Lab 4% 19% 42% 28% 6%

Outpatient/ambulatory 4% 21% 40% 28% 6%

Survey Results

FiGURE1 | Operations Area With Greatest Return in efficiency improvement or Cost Reduction

Q | Which area of hospital operations could yield the greatest return in efficiency improvement or cost reduction?

base = 250

0 5 10 15 20 25 30

30%

26%

16%

11%

8%

3%

2%

4%

Revenue cycle

Clinical operations, skilled and technical staff

Purchasing/supply chain

Administrative/fiscal overhead areas

Departmental directors/managers and mid-level leadership

Physical plant and environmental savings

Support services, skilled and technical staff

Other

FiGURE2| Difficulty of Achieving Results in improved efficiency and Cost Reduction by Clinical Area

Q | Please rate the following clinical areas on the difficulty of achieving results in improved efficiency and cost reduction.

base = 250



page 14


01020304050607080

16%

67%

17%

Survey Results (continued)

FiGURE3| Use of information technology to Guide Cost efficiency programs

Q | Which statement best describes how your organization currently uses information technology to guide cost efficiency programs?

base = 250

We have robust clinical and financial data

integrated with solid business intelligence and

analytical tools to guide us

We have some reliable clinical and financial data that we use to

achieve results

We lack clinical and financial data for improvement at

this time

FiGURE4 | Most Critical Need for performance Data Measurement

Q | Which performance data measurement is your most critical need?

0 5 10 15 20 25 30 35

32%

26%

18%

14%

7%

3%

Throughput and efficiency

Clinical outcomes

Actual labor productivity

Individual clinician performance

Ambulatory service line costs

Other

base = 250



page 15


0

5

10

15

20

25

30

22%

29%

22%

27%


FiGURE5| Staff Resources Dedicated to Cost Reduction and efficiency

Q | Please describe the staff resources your organization has dedicated to cost reduction and efficiency.

base = 250

0 FTEs 1–2 FTEs 2–5 FTEs 5+ FTEs

FiGURE6 | efficiency techniques or Systems Currently in Use

Q | Which of the following efficiency techniques or systems does your organization currently use?

0 10 20 30 40 50 60

57%

50%

50%

32%

Business process management/Continuous improvement process

Balanced scorecard

Lean

Six Sigma/TQM

base = 250Multi Response



page 16


0%–2% 3%–5% 6%–10%Higher

than 10% Base

Pharmacy 16% 16% 26% 42% 19

Executive/administrative 60% – 20% 20% 5

Physicians (hospitalists, ED physicians, etc.) 25% 27% 28% 20% 60

Supply chain 4% 50% 27% 19% 26

Billing and collections 21% 33% 27% 18% 33

Food and nutrition services 16% 37% 32% 16% 76

Information technology services 29% 32% 24% 15% 34

Environmental services 18% 49% 18% 14% 49

Lab 32% 37% 21% 11% 19

Nursing staff 36% 36% 18% 9% 11

Plant operations 41% 47% 6% 6% 17


FiGURE7 | Critical Functions Outsourced

Q | What critical functions has your organization outsourced?

0 5 10 15 20 25 30

30%

24%

20%

14%

13%

10%

8%

8%

7%

4%

2%

29%

Food and nutrition services

Physicians

Environmental services

IT services

Billing and collections

Supply chain

Lab

Pharmacy

Plant operations

Nurse staffing

Executive/administrative

Nonebase = 250Multi Response

FiGURE8| Year-Over-Year Direct Savings for Outsourced Functions

Q | For each of the functions your organization outsourced, quantify the year-over-year direct savings.

base = 250



page 17



FiGURE9| Average Annual Savings From Cost Reduction programs

Q | What is your average annual savings from cost reduction programs over the past three years?

0

10

20

30

40

50

0% 1%–3% 4%–5% 6%–10% 11%–20% More than 20%

1%

41%

29%

21%

5%3%

base = 250

FiGURE10| Additional Cost to pull out of Operating budget

Q | Even with your cost reduction initiatives so far, how much additional cost remains to pull out of your operating budget?

0

5

10

15

20

25

30

0% 1%–3% 4%–5% 6%–10% 11%–20% More than 20%

2%

20%

29%26%

14%

9%

base = 250



page 18



FiGURE12| Cost Reduction initiative Failure

Q | Have you ever had a cost reduction initiative fail to achieve planned results?

FiGURE11 | biggest Obstacle to Cost Reduction

Q | What is your organization’s single biggest obstacle to successful cost reduction?

0 5 10 15 20 25 30

30%

16%

16%

10%

8%

7%

6%

5%

2%

Reducing cost while also maintaining service and outcomes

Lack of accountability, follow-through

Physician resistance

Lack of sustainable process for attacking cost

Leadership’s lack of understanding the urgency for accelerated change

Insufficient IT and/or professional infrastructure

Staff resistance

Lack of monitoring, measurement

Other

base = 250

68%Yes

32%No

base = 250



page 19



FiGURE13 | Main Cause of Failure

Q | What was the main cause of the failure?

0 5 10 15 20 25

23%

23%

22%

18%

8%

6%

Cost gains were overestimated

Poorly planned/implemented

Lack of leadership support/infighting

Not enough resources dedicated

Fatigue/took too long

Other

base = 171Among those organizations who have had a failure

FiGURE14 | Method of Sharing Cost Savings Among Stakeholders

Q | When your organization implements cost containment, how do you share the savings among stakeholders?

0 10 20 30 40 50

48%

30%

10%

9%

4%

Savings are not shared

Direct benefit is realized at the facility level

Implement a bonus structure for participants

Use a percentage of the savings for discretionary reinvestment in that department or organization

Other

base = 250



page 20


Improved DeclinedStays the

same

Clinical outcomes 44% 4% 52%

Patient satisfaction 39% 10% 51%

Employee satisfaction 33% 37% 30%

FiGURE15| Areas of performance Affected by programs that eliminate Waste and Reduce Cost

Q | Please describe how other areas of performance have been affected by your organization’s programs that eliminate waste and reduce cost.

base = 250



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