Patients signing similar forms and answering the same questions three or four times.
Nurses going in and out of rooms searching for medical supplies.
Patients moving from room to room at great discomfort, for the convenience of clinical staff.
Patients leaving a doctor’s office without test results or a plan of care.
This is crazy, Toussaint recalls about what he witnessed as an internal medicine practitioner. Then one day, he began talking with the chief executive officer of a certain snow blower and lawnmower manufacturer in Brillion, and it hit him: there must be a better way.
Along with other senior leaders from the ThedaCare health system, Toussaint took ideas from followers of the Toyota lean manufacturing model and created a lean health care process that has saved millions of dollars while improving quality.
“There was so much waste and so many mistakes made getting patients to the right doctor or to get them to the right tests. There were so many headaches and hand-offs. The entire process was frustrating,” says Toussaint, who recently released a book On the Mend, which chronicles ThedaCare’s lean story.
That frustration led him out of the exam room and into the corporate office suite at UnitedHealth and its successor, ThedaCare. Then president and CEO of the largest New North employer, with more than 5,400 workers, Toussaint quickly saw the effect rising insurance costs had on the organization’s bottom line.
“I realized that we can’t keep going on this path of rising health costs. Our economy can’t handle it,” says Toussaint, who served as ThedaCare’s CEO from 2000 through 2008, when he left to launch the ThedaCare Center for Healthcare Value.
Toussaint says in Wisconsin, the cost of care is relatively low and the effectiveness of care, high. According to the Dartmouth Atlas of Health Care, patient outcomes for comparable procedures among Medicare patients 65 and older rank in the 88th percentile in Green Bay and Appleton, while costs average about $6,950. Compare that to Miami, Fla., where outcomes rank 77 percent and costs average $17,274; or McAllen, Texas, where outcomes rank 74 percent and costs average $15,700.
Health care systems here clearly are taking innovative approaches to hold the line on costs. Appleton’s ThedaCare changed how patients are treated in the hospital setting. Affinity Health System of Menasha reinvented the way patients and their primary care providers interact through its home medical model. Bellin Health of Green Bay created a way to keep patients out of costly emergency rooms by providing urgent care services at local retailers.
“Northeast Wisconsin is a leader in health care innovation,” says U.S. Rep. Steve Kagen, D-Appleton. An allergist, Kagen is familiar with the successes and failings of the American health system. “The fingerprints of what we’re doing – and what we need here in Northeast Wisconsin – are all over the new health care laws.”
Under Toussaint’s leadership, ThedaCare became a national leader in implementing lean practices in health care and cutting millions of dollars in waste, while improving quality measures at its 22 clinics and four hospitals. In three years, ThedaCare saved an amount equal to 5 percent of its annual revenue, while doubling its operating margin.
Those results have been recognized by experts across the country – including former U.S. Treasury Secretary Paul O’Neill – and led Toussaint to step down as ThedaCare CEO and create the ThedaCare Center for Healthcare Value two years ago.
“In my mind, the ideas practiced at ThedaCare should be adopted across the country,” says O’Neill in a review of On the Mend. “If they are, it will be easy to afford financial access to health care for every citizen, because we will reduce national medical care spending by hundreds of billions of dollars per year, while improving outcomes.”
Toussaint addressed the Washington Press Club in early August about electronic medical records and how they can transform the health care process. He was also recently quoted in a New York Times article about Dr. Donald Berwick, the new Medicare and Medicaid chief.
Toussaint – who is so passionate about his lean health care message that he put on a homely hospital gown and posed as a patient for the Insight photo shoot – is still on the journey he began in 2002 at Ariens Co. in Brillion. That’s where he saw the manufacturing lean process in action and began thinking about ways to take that model and adjust it so it would work for health care providers.
“Being in the exam room with patients and seeing how the whole process wasn’t working is what got me started on this journey to improve patient care,” says Toussaint, who often leaves his tie and suit coat at home and gets on the level with medical staff to find out what works and what doesn’t.
It’s a journey he’s still on, but one he’s not traveling alone.
Looking for solutions
Ask anyone and they’ll tell you change is needed in health care. But when it comes to what that change should be and how it should be implemented, nearly everyone has a different opinion and idea for how to fix what’s wrong.
Despite this year’s landmark health care legislation, Toussaint says there are three areas needing improvement before real reform is realized: more transparency of costs and outcomes, changing the way care is delivered and modifying the pay structure to reward providers for quality – not quantity.
“The hardest thing to change is how care is delivered, since people are ingrained with how things are. Right now, you have 6,000 hospitals all doing it a different way,” says Toussaint, who has traveled around the country sharing ThedaCare’s story and inspiring other health care systems to embark on the same journey.
One way ThedaCare is changing care delivery in the hospital setting is through its Collaborative Care model. Developed by employees using lean principles, Collaborative Care brings together a team of medical providers, including a physician, nurse and pharmacist, to work with patients and develop a plan of care for their hospital stay. What they’re doing is so different that the health system is in the process of having Collaborative Care patented.
“We have seen with Collaborative Care that you not only improve patient quality, safety and satisfaction, but also lower costs. We started Collaborative Care in one unit at Appleton Medical Center and are copying what we’ve learned and continuously improving and customizing it for each unit,” says Dr. Dean Gruner, who took over from Toussaint as ThedaCare’s CEO and president in 2008. “We take the best and continuously improve.”
ThedaCare just opened its new pavilion at Appleton Medical Center as part of its $90 million initiative to implement Collaborative Care at its Fox Cities hospitals. As part of the project, all patient rooms at AMC were replaced; rooms are being remodeled at Theda Clark in Neenah.
“The health care bill really lays the groundwork for changing how health care providers will be paid,” says Gruner, a family practitioner in Appleton for 20 years. “Health care systems will need to figure out how to improve quality while keeping costs down. At ThedaCare, I believe we have the right platform for that. We have the technology – our Epic medical electronic record systems make sure providers have patient information at their fingertips. We have the personnel – dedicated staff who are interested in constantly providing better care and service to our patients.”
As recognition of the way it uses technology to provide better care for patients, ThedaCare this summer was named one of the nation’s Most Wired health systems for the ninth year in a row by Hospitals & Health Networks magazine, the journal of the American Hospital Association.
Affinity Health System, which is headquartered in Menasha and operates Affinity Medical Group, three hospitals and Network Health Plan, initiated its Affinity Medical Home model as a way to improve patient care in a clinical setting while keeping costs down.
In this care model, patients are assigned a team of providers at their local clinic, including a physician, nurse, health care associates and other specialists if needed. As a result, patients and providers form a closer relationship that ensures individual needs are being met. So far, it has been rolled out to 14 Affinity clinics.
“Providers work more closely with patients and can catch and treat problems before they get too serious,” says Affinity’s CEO and president Dan Neufelder. “It’s a great situation for people with chronic diseases, such as diabetes. Studies have shown that people in this type of model tend to be healthier over the long term and costs come down because they aren’t waiting until something is an emergency to act. There’s no doubt prevention leads to lower costs.”
Since Affinity launched its medical home model, the number of primary care office visits has increased, but the number of hospital admissions is down, Neufelder says. “The most cost-effective place to deliver health care is in a primary care provider’s office,” he adds.
Neufelder says Affinity is in a unique position following the passage of the health care reform legislation since it not only is a medical provider, but also provides insurance.
“The legislation opens up a new era for health care providers and insurance companies. We feel Affinity is in a good place since we bring together hospitals, providers and the insurance company under one umbrella,” he says.
Tucked in the 2,000-page health care reform bill is something that caught Neufelder’s eye: the creation of state insurance exchanges. He believes those exchanges can only mean good things for regional insurance providers, such as Affinity’s Network Health.
“It will be the Travelocity of health care – you will be able to compare programs side by side to see where you can get the best deal. It’s exciting. A single person buying insurance will be able to get the same rate as a multi-national company,” he says.
The retail approach
For Bellin Health, a suggestion from a retailer to offer onsite health services led to a burgeoning division, FastCare, which has taken the Green Bay-based health system across Wisconsin and the country. The first FastCare, staffed by a nurse practitioner, opened four years ago at a Green Bay Shopko store. The nurse practitioner can run some tests, such as for strep throat or a bladder infection, check ears for infection and other basic diagnosis involving acute illness. In Wisconsin, nurse practitioners are also licensed to write prescriptions.
FastCare allows patients to seek medical attention when they want it – including evenings and weekends – when many doctors’ offices are closed.
“That first FastCare was so successful we decided to spread it,” says Ken Berndt, Bellin Health’s director of FastCare development. “We started partnering with other health systems for them to open their own version of FastCare in a retail location. We have such a successful model that we’ve been able to take it and replicate it elsewhere.”
Berndt says FastCare keeps patients out of hospital emergency departments. “Going to an emergency room is one of the most expensive ways to get care and that’s what a lot of people previously did,” he says.
Nearly half of FastCare patients surveyed indicated they did not have a primary care provider.
A typical visit to FastCare costs about $54, which is one-tenth the cost of a visit to the ER and about half the cost of a visit to a primary care provider.
“Originally primary care providers were leery, thinking FastCare would cut into their volume, but that’s not the case,” Berndt says. “Visits grew to primary care providers by 6 percent because we’re attracting people into our health system who wouldn’t have come to us otherwise.”
Bellin is also setting up FastCare clinics for other health systems. Bellin puts the processes in place and then hands it over to the health care system. So far, health systems in Milwaukee, Beaver Dam, Monroe, Wausau and Appleton’s ThedaCare have all worked with Bellin on their own FastCare clinics.
“We’ve found that FastCare is a win-win-win: Employers like it because it keeps health costs down, patients like it because they get the care they need when they need it and it’s good for the health system since we’re able to tap into a new population that hadn’t been coming to us before,” Berndt says.
A health care mecca
Since starting the ThedaCare Center for Healthcare Value two years ago , John Toussaint has turned Appleton into a mecca for health care systems looking to hold costs in line while improving patient quality.
Visitors from health care systems from around the world are common at ThedaCare’s Friday morning gatherings where employees involved in that week’s rapid improvement events share their experiences. Beyond that, some officials, such as Dr. Carolyn Clancy, director of the Washington-based Agency for Healthcare Research and Quality, come for private visits with Toussaint and to tour local facilities.
Toussaint has also hosted 60 health care system leaders from across the country at the Healthcare Quality Value Network, where visitors learn lean techniques to help them cut waste while improving care.
“I constantly receive requests from people to come and talk about what we’re doing in Appleton and how we’ve succeeded,” he says. “I guess that’s why we wrote On the Mend, so we can share with even more people about how we’ve made these changes. Change is definitely needed – we can’t keep going on the way we are going in this country. I think that’s something we all realize. We just have to figure out how to get there.”