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Why We're Proud to Work at Dartmouth-Hitchcock

Why We're Proud to Work at Dartmouth-Hitchcock

Past, Present and Future: Creating a Sustainable Health System at Dartmouth-Hitchcock

We all know that Dartmouth-Hitchcock has had a long and proud history, all 122 years of it, dating back to the founding of Mary Hitchcock Memorial Hospital in Hanover in 1893, and even further, back to the founding of Dartmouth Medical School—now the Geisel School of Medicine—as the nation's fourth-oldest medical school, in 1797.

But how can we call on that rich history to inform us as we solve the serious challenges facing the nation's health care system? There are concrete steps Dartmouth-Hitchcock (D-H) is already taking toward a solution, and D-H is playing a leadership role in helping to create a sustainable health system.

So, just WHAT is the problem?

For decades, the nation's health care system has been based on the fee-for-service payment system. It's one that rewards organizations with the greater the revenue for more procedures. All the financial incentives in the fee-for-service payment system were designed to increase the volume of procedures and increase market share.

It's a system that continually drives up costs, and if we focus on volume, we often treat only the symptoms of chronic diseases completely missing their underlying causes.

It's a system in which 20 percent of the public produces 80 percent of the health care costs. It's a system that results in those costs eating up almost a quarter of the state's budget. And, it's a system that's left states, like New Hampshire and Vermont, as well as businesses, large and small, reeling under the cost of health care.

In short, it's a system that simply is not sustainable.

This all raises the questions of WHERE we should take the health care system and HOW we should do it.

But first, let's examine WHY we are all here at Dartmouth-Hitchcock. Certainly, individual reasons vary. But at the heart of it, we have all, in one way or another, answered a call to public service: to care for patients and their families, and to make a difference in their lives and those of their communities.

Dartmouth-Hitchcock is here to provide the tools, resources, infrastructure and planning needed to create the best possible environment—both for treating the patients of today and tomorrow and for you, the caregivers, to carry out your great work now and in the future.

I'm sure you've all seen D-H's Imagine Card. It describes the vision of our institution, and can provide the vision for this country's entire health system. It's WHY D-H is here:

Imagine a sustainable health system with one goal: to improve the lives of the people and communities we serve, for generations to come.

What does such a system look like, what are its distinguishing characteristics? Simply put:

Imagine a health system that focuses on health, not just health care.
Imagine a health system where care is based on value, not volume.
Imagine a health system grounded in population-based strategy, not market share.
Imagine a health system where patients, when well informed, receive only the care they want and need.

This is the vision of Dartmouth-Hitchcock: our WHY.

So, just WHERE are we now, WHERE are we going and HOW will we get to the point of realizing that vision?

First, we need to recognize that health care sometimes fails to provide consumers with the service they demand, and the service they deserve. Health care practices have often not kept up with the myriad changes in our society—a society increasingly interconnected and constantly evolving.

In today's world, you can compare and shop for the best loan interest rates, and highest rated products and best the prices.

But health care? With some exceptions, and D-H has been one, health care has continued on in its old plodding way. You want treatment? Come to the provider, no matter how far the drive or inconvenient the hour. Procedures, medications and imaging were often over-prescribed. And forget about understanding prices or the quality of health outcomes being shared with you.

We need to arrive at a health system that both lowers costs and provides higher quality of care: a system that is sustainable for all involved in D-H's services—patients, providers, insurers, businesses and communities. Individual patient outcomes and overall community health would improve. The direct and indirect burdens on government budgets and businesses would lessen.

To get there, the answer is to create a sustainable health system. Sustainability means reaching out to the community and rewarding the quality of care over the volume of care—while reducing costs.

But it's just theory until you determine how to make the change, and then carry it out. The opportunity to put these theories, which I've long held, into practice was one of the key appeals of my current position. But you can't Google "create a sustainable health system," then put those coordinates into a GPS to find your way there.

So, just HOW do we get there? HOW do we make the WHY of D-H—our vision—a reality? With a lot of hard work on the part of colleagues here, our institution mapped out the HOW in the matrix "Creating a Sustainable Health System."

It's Dartmouth-Hitchcock's roadmap for bringing our vision to life through our doctors, nurses, administrators and staff ... working with our health care partners, for our patients and their families, across the communities we serve, for generations to come.

D-H's strategic matrix, our roadmap, is built on three core strategies with measurable milestones:

  • improve population health
  • reward quality, not quantity, of care through value-based care
  • develop successful new payment models

If we, working together, can deliver on D-H's WHY—our vision, and HOW—our roadmap, we can help build a future health system that is sustainable and improves the lives of the people and communities we serve. It's a future that will provide dramatically better care at a reduced cost. And, I believe, it is a future that will make you prouder than ever of the role you play here—a future that our country longs for.

As we all know, the health care field has a dizzying array of terms, and the move to the new system involves two terms not readily recognized by the general public: "capitated" and "risk-based."

I describe capitated as essentially meaning that fees are set per patient, regardless of the amount of treatment required. And in this context, risk-based means upending the traditional fee-for-service model—where the insurer takes the risk of having to pay for all procedures, no matter how expensive—and set its rates accordingly.

D-H strongly advocates a switch to a model in which the health care provider (that's us) assumes the risk of experiencing significant financial losses if those fees are not set at the correct level. We propose working in partnership with our patients who, when well-informed,  receive what they want and need—the very essence of shared decision-making.

Much work remains before we can reach this ideal. But the good news is that we definitely are not starting from scratch: far from it. D-H has already made major strides toward arriving at a sustainable health system.

Dartmouth-Hitchcock is a major player in the national health care discussion. Emphasizing quality over quantity is the direction Medicare is now aggressively pursuing. And—as you well know—wherever Medicare and Medicaid are headed is where health care policy tends to follow.

In just the last three years we have transformed our business model into one that is 50 percent fee-for-service and 50 percent capitated/risk-based payment. We are firmly committed to raising that capitated/risk-based percentage to a full 70 percent—and, sooner rather than later, to near-full capitation.

D-H is no stranger to the move away from fee-for-service. We have been at the forefront, participating in the original, federal Physician Group Practice Demonstration project—the precursor to the ACO (Accountable Care Organizations) movement.

We have dramatically stepped up the number of regional health system partnerships and alliances in which we are engaged. They have the effect of improving collaboration to benefit both patients and their families.

These partnerships and alliances include:

  • Six CVS Minute Clinics across New Hampshire
  • The Center for Telehealth, serving the needs of smaller hospitals, including the Center for Rural Emergency Services and Trauma (CREST) network
  • The New England Alliance for Health (NEAH)
  • The OneCare Vermont Accountable Care Organization
  • Population-based health initiatives that annually provide $220 million worth of community health-focused support, including initiatives carried out by Partners for Community Wellness
  • Our affiliate hospitals: Cheshire Medical Center, Mt. Ascutney Hospital, and New London Hospital, with other affiliations in discussion and under review

Surprising to many on the outside—and to some of you on the inside—is that these partnerships intentionally result in lowering revenues to D-H, rather than increasing them. We are doing this because it's the future of a sustainable health system, not health care system.

And that's only part of the story. D-H prides itself on providing our services to consumers where they need it, not just where we are. For decades, when our patients needed treatment they had to come to the hospital, no matter the distance, but no more. Now we can go to them, or be closer to where they live and work.

We are paying attention to the changing demographics of our region. With 80 percent of those living in New Hampshire now residing in areas from Concord south, we now serve that area with outpatient service through our Community Group Practices, with more than 30 clinic locations across New Hampshire and Vermont, and fifty telehealth locations across three states. This brings needed medical expertise and services closer-to-home. It provides greater convenience and access—reserving trips to our hospitals for more acute, inpatient treatment—saving our consumers both time and money.

We're also on the verge of piloting our ImagineCare Digital Health platform, utilizing cutting-edge technology in partnership with Microsoft, to bring care to our patients when and where they need it.

And we've introduced a health insurance product, ElevateHealth, that further upholds our vision. It is less expensive than any other New Hampshire insurance product. Again, this means less revenue to D-H than if we just let the current system continue on uninterrupted. But we are doing the right thing to make the system sustainable—bringing down costs, while still improving care quality. In the coming months, we intend to expand these efforts and add more benefits for our patients in New Hampshire.

We also seek to be as transparent as possible. I've often made the analogy that, traditionally, our nation's health care system is run like flying a plane with no control panel. Today's health care consumer is flying blind—with no sense of costs and no sense of the value or quality of results. D-H has been a leader in transparency—posting on our website both our costs and the health outcomes of our patients.

Now, I realize that I've portrayed D-H in a very favorable light. And it's a portrayal I'm sure all of us feel very strongly is an accurate one. But lest I leave you with the impression that any of us should think of ourselves as perfect: as the leader of our system I'm grateful to know that our work to improve will never be done.

Take, for example, our sepsis work. We saw that our numbers were not where they should be, and said we must create a plan to improve in less than six months, not six years. We did that. We saved 42 more lives than the year before. That's because we applied our strategy of quality, not quantity, of care. We were humble enough to address an area where we needed to improve. We learned from others who had achieved evidence-based success, and we got better. Isn't this what D-H is about, being the very best we can be for each and every patient and for each other?

As we move forward, it's important that we continue to recognize where we can be better as we constantly strive to improve our services.

Our WHY—our vision, and HOW—our roadmap, set out what we are trying to achieve and how to do so.

It's a future that includes vastly more emphasis on comprehensive treatment, closer to home. Now, those who repeatedly return to hospital emergency rooms for treatment are provided service for whatever acute medical condition they may be suffering at the time. But, they often are not receiving treatment for the underlying cause of their chronic medical problems.Without treatment of the underlying cause, they are destined to return to the ER or hospitalization time and again—dramatically driving up health care expenses, while enduring poor health outcomes and a poor quality of life. The domino effect—on family, on business on communities—is astronomical.

In the future, providing counseling and treatment near or in a patient's home to deal with their underlying chronic disease—a consumer-based approach, not a hospital-based approach—often in partnerships with outside organizations and often using easy-to-use telehealth technologies—will be an increasing hallmark of D-H's care, resulting in both better outcomes and reduced costs. This is what we're working on at ImagineCare Digital Health, a remote medical sensing initiative, in partnership with Microsoft, that leverages technology to bring health and wellness to our patients when and where they need it.

All of this allows us to build on our 122 years of service to the community, positioning us to continue that service for another 122 years.

Thanks to your hard work and dedication, it's a new health system that has already taken great strides to improve care to patients across New Hampshire and Vermont, and expanding further through partnerships and telehealth. It's what we are determined to deliver and, with you—with your support, your advocacy and your dedication—it's exactly what we will achieve.

Thank you for being part of the D-H family. It's an awesome responsibility, and yet we all need to remain committed to each other, to be all that we can be, to create a sustainable health system, to improve the lives and the people and communities we serve, for generations to come.