NewYork-Presbyterian CEO Steven Corwin has patient access on his mind.
The academic health system late last month opened the doors to the David H. Koch Center, an ambulatory care facility including outpatient surgery, interventional radiology and diagnostic imaging services. The 740,000-square-foot center is the latest in NYP's efforts to rethink how to engage patients.
Among the other efforts: NYP this month expanded its mobile stroke treatment unit to encompass three of the five New York boroughs. In December, the provider partnered with Walgreens to improve access to telemedicine services.
"Unless we get care to the ambulatory setting and more convenient settings, we're not going to be able to reduce the cost of care in the country," Corwin told Healthcare Dive in an interview while on a recent visit to Washington, D.C. He called out prices of care services, pharmaceuticals and devices as the main culprits for the rise of healthcare spending in the U.S.
"I'm responsible for hospital pricing. If I can move care to less expensive settings, that's really what my role should be," he said.
Corwin, CEO since 2011 and a member of NYP's management team since 1998, echoes hospital CEOs around the nation who are rethinking their business models. In the past decade, NYP has experienced a 40% increase in inpatient days while outpatient visits have increased by 53%. Emergency visits have increased by about 66% since 2008.
"Emergency departments are very expensive [and] very crowded. If we can off-load the emergency department, patients would be much happier if we do it responsibly," Corwin said. "There's no question more and more care is [going] ambulatory and I think that's better for the patients."
In the interview, Corwin discussed NYP's flirtation with Amazon for supply chain engagement, the organization's telemedicine efforts and whether artificial intelligence will replace the human factor in care delivery.
Here are the highlights.
1) Artificial intelligence will have big wins for administration, but clinical use still needs oversight
Corwin isn't ready to concede human oversight to the machines in a clinical setting just yet, but believes there will be significant disruption in the area in the next five years to get to advanced predictive analytics.
"I do think that the doctor can be aided in making the decision," Corwin said, adding doctors will be more willing to accept AI and machine learning if they help them, as opposed to replace them. "Physicians want to be aided in diagnosis and treatment," he said.
Hospital margins have tightened. Last month, Moody's reported that median operating margins for nonprofit hospitals sunk to 8.1% in 2017, a 10-year low.
In addition to rethinking patient engagement and asset management, some organizations are looking at artificial intelligence and machine learning to help with administrative tasks. Corwin name-checked the automation of finances and virtual assistant chatbots as "big win" technology investments for care delivery organizations.
Easing repetitive tasks for employees to improve operations can help manage a hospital, Corwin said. NYP is currently using nudges generated by machines to help schedule social work consults or MRI scans to manage patients' length of inpatient stay. The organization is finding positive results initially, but the effort will need to be studied, Corwin added.
For Corwin, larger issues over AI and machine learning include validating value sets and removing any unintended biases from AI systems as well as what the technology means for healthcare jobs over time.
"Certainly there's going to be retraining," he said. "We have to have more emphasis on STEM education for people coming into hospitals. Some of the lower-level jobs may be replaced and we'll have to find new jobs for those employees to do. If we can't convince our employees that there's a net benefit to them, then we're going to have difficulty getting them to adopt [such technologies]."
2) Amazon didn't get better pricing for part of NYP's supply chain
Corwin disclosed that NYP worked with Amazon on a supply chain deal, with tepid results.
"We gave them a piece of our supply chain to see whether they could get us better pricing and the answer to that was no," Corwin said.
A recent Reaction Data survey found 62% of healthcare executives are hoping Amazon can shake up the industry's supply chain. A Wall Street Journal report from February said the e-commerce giant had been piloting a supply chain program with a large Midwestern hospital system using Amazon Business, its business-to-business marketplace, for a portion of its outpatient facilities.
The healthcare supply chain space is already dominated by Cardinal Health, McKesson and AmerisourceBergen, so it's currently unclear how seriously Amazon will pursue the space.
"The general rule of thumb is you're looking at the stock market and Amazon is getting into a business, [stocks will sell]," Corwin said.
Still, he added: Amazon is "brilliantly led and I wouldn't underestimate them."
3) Hospitals need to rethink patient engagement strategies
"We've got to move outside the [hospital's] walls," Corwin said. "It's part of the movement toward getting away from being responsible for the acute care episodes to having a more holistic view of healthcare."
The American population is getting older, and younger generations don't want to wait around to schedule doctors appointments. That's changing the dynamics of patient volumes for hospitals.
Corwin sees sicker patients entering hospitals in the future, forcing organizations to re-imagine intensive therapy and what inpatient hospital care looks like. Bed complements for ICU units and staffing levels are administrative considerations needing to be reviewed over the next 10 to 20 years.
It's part of grander industry sea change. More patients are choosing outpatient services for less intensive care. Moody's Investor Service this month said health systems overall will need to be flexible with business strategies going forward, stressing a balance of both inpatient and outpatient investments.
To Corwin, that translates to more in-home visits, school-based clinics and on-demand care capabilities in various settings — such as kiosks — so patients interact with the provider.
"The convenience factor for patients makes a difference," Corwin said, adding the registration time at the new ambulatory building is about 90 seconds. Patients check in with a kiosk and can be located if needed via RFID bands while at the facility.
It's part of the reason he believes consumer-based principles will be more important for providers than a topic such as behavioral economics. "Healthcare has been the last [industry] to be disrupted but it has to be," Corwin said. "If we can do it in such a way where people feel we've maintained the human connection and made it easier, that's the holy grail. Right now I think people think that consumers think we're too hard to access."
4) Telehealth could be a big part of that strategy but ROI is still a question
NYP made a decision a few years ago to go deep into telemedicine on the assumption it provides better access and reduces costs.
The effort includes the mobile stroke units as well as telepsychiatry and urgent care kiosks in the emergency department. Altogether, NYP has found patients have taken to the service. The organization conducted 1,600 visits in 2016 and did 12,000 the next year. Corwin expects that NYP will conduct 100,000 televisits this year.
However, when it comes to ROI, Corwin said the jury is still out.
"I think it's the question," he said. Providers are currently questioning if the service offers a value-add. Medicare and other payers are concerned if healthcare costs will go up initially because patients and providers will have the ability to engage with teleservices, potentially driving up the number of claims to process.
"I don't think we have enough data," Corwin said. "You have to take a look over a long period of time. In the more chronic conditions, proving ROI ... is going to be a more difficult challenge. You have to show outcomes are better, costs are down and access is better."
Still, Corwin is a big believer in the service, pointing to its ability to treat patients quickly and triage with multiple care team members.
He gave an example of a follow-up office visit for a congestive health failure patient, which he said is typically between 15 and 20 minutes. A sick patient with heart failure could take eight to 10 minutes to get undressed and redressed, giving the physician limited time with the patient. That offers little time to review diet, medications and social situations in the patient's home. Telemedicine triaging can help, he said.
"If you start to imagine it somewhat differently, if you had a pharmacist, social worker [and] nutritionist available and you can stack the work so that these people could be covering multiple sites simultaneously, then you fundamentally change the nature of the visit," Corwin said.
Use cases, in this view, become varied over time, he said. The organization is now working on getting disparate workflows to align as a team via telemedicine.