- With anticipated population growth, Lee Health needs to add more capacity, which in turn creates the opportunity to add to the depth and breadth of services offered and to establish a best-in-class regional health system
- Key features of the regional system would include:
- Nationally recognized sub-specialty centers of excellence
- Further integration
- Developing a geriatric center of excellence
- Expanding Lee Health’s health insurance offerings
- Pursuing mergers, acquisitions, and affiliations
- Working with others to improve social and economic conditions that affect health
- Working with others to address health disparities
Lee County has been discovered. The US News and World Report has deemed the Fort Myers/Cape Coral area the number one place in the country to retire. Our population is growing by 2-3% each year. In the last decade, we have added 150,000 residents, which is the size of a medium city. Our Lee County metropolitan area (which includes Charlotte, Collier, DeSoto, Glades, Hendry and Lee counties) now has about 1.4 million residents and is expected to have 1.7 million by 2025.
This growth will require Lee Health to add capacity. It will also enable the system to add breadth and depth to its services. There is the further possibility of Lee Health assuming a leadership role in organizing the currently, fragmented care delivery in the region. Lee Health could evolve to be the Regional Southwest Florida Health System.
This type of scaling is found across the country. Just maintaining the status quo is increasingly not an option. Hospitals and systems are being compelled to find partners – the only choice they have is whether to lead or to follow.
Lee Health, because of its size and talent, should be in a leadership role.
In this regard, there are seven opportunities worthy of strong consideration by Lee Health that would serve as building blocks in establishing a Regional Southwest Florida Health System. Having these blocks in place would increase Lee Health’s attractiveness as a potential partner. Initiatives could include:
- Developing nationally recognized, highest-quality tertiary and quaternary care centers of excellence
- Further integrating the Lee Health system to facilitate continuity of care and to assure the highest quality delivered
- Developing a geriatric center of excellence, recognizing the unique challenges in caring for frail, polychronically ill older patients
- Further developing Lee Health’s health insurance products and population health management arrangements with the payers to provide flexibility in creating best pathways of care delivery systems and to align economic incentives
- Evaluating and as indicated, pursuing merger, acquisition and affiliation opportunities with health systems, free-standing facilities and medical groups located throughout southwest Florida
- Working with government, other providers and community-based organizations to improve the social and economic conditions that affect health
- Working with government, other providers and community-based organizations to address health disparities
National Centers of Excellence
With 1.7 million residents, Lee Health will have the critical population mass to provide outstanding medical care for almost all conditions. Patient volumes will be large enough to support the sub-specialists needed for Lee Health service lines to be recognized as national centers of excellence. This would allow us to stop sending our most difficult cases to Miami or Tampa, which are where the closest nationally recognized centers of excellence are located. Patients residing in Charlotte and Collier Counties could be instead referred to Lee Health.
Being nationally recognized would also help to locally strengthen the Lee Health brand, which as the market becomes more competitive is particularly important. Health care consumers and their doctors always prefer top quality.
Stress on patients and families would be reduced with shortened travel distances. Because of easier access to the specialists there would be better post-acute care, too.
The increased referral volume would also aid in economic development with the many well-paying jobs that would be created.
Integrated Care Delivery
Continuity of care matters and is one of the key reasons for having an integrated system of care. Lee Health has done an excellent job assembling many of the elements of a fully integrated system. These include the Lee Physician Group, Lee Health’s close relationship with many of its independent medical staff, and its various acute, ambulatory, urgent care and post-acute sites of care.
Having most providers use the Epic medical record is also extremely helpful. With providers knowing each other so well, higher quality care is delivered to their shared patients. Resources are also conserved as unnecessary duplication of testing and services is avoided.
Lee Health should evaluate the potential benefits of further integration. Recent innovations in telemedicine and tele-monitoring deserve special consideration by both the medical staff and the home health agency. Virtual visits and remote monitoring are often as good, if not better, than in-person care. Patients and families find them more convenient. Further, their use helps with affordability as unneeded admissions or trips to the ED or urgent care center are avoided.
Geriatric Center of Excellence
Lee County’s population is older. Thirty percent of Lee residents are over 65 compared to a national average of 13 percent. Nine percent are over 80 compared to a national average of less than 2 percent.
Many of these older residents suffer multiple chronic conditions. They have musculoskeletal, heart and lung disease. They are diabetics. They are clinically depressed. It is not uncommon for them to take 10 or more prescription medications each day. Therapeutic compliance is a constant challenge. Many live alone.
These patients, who comprise a disproportionate share of our population, are very difficult to manage. Candidly, their medical conditions compete. Coordinating care among specialists is often hard. The social issues, including transportation, nutrition and housing, are sometimes overwhelming.
In reviewing integration, attention should be provided to the possible creation of a geriatrics service line devoted to caring for these “sickest of the sick” patients.
Better coordination of physician and nursing care and social services would allow patients to age in place and avoid expensive hospital admissions and readmissions as well as nursing home placements.
There may also be some unique opportunities to provide medical services in long-term care facilities, with the objective of avoiding transfers to the hospitals. Again, recent advances in telemedicine and telemonitoring may be helpful here.
Managing integration especially for the sickest geriatric patients requires specialized administrative and clinical competencies.
Lee Health’s Health Insurance Products
One of the often-heard reasons for not transforming care delivery to be more efficient is that the economic incentives are not supportive. Providers receive more revenue and generally produce larger margins if they deliver more services. This type of arrangement is called fee-for-service or volume-based payment.
An alternative approach is to pay the provider a risk-adjusted, single comprehensive fee for caring for a patient, regardless of the services the patient receives. This could be a bundled, episodic payment. Or it could be a capitation payment; that is, a fixed amount to care for a patient for a period of time, like a month or year. This type of reimbursement is called value-based payment. Sorry for all the jargon here!
In addition to promoting efficiency and affordability, value-based reimbursement also offers providers some flexibility regarding pathways of care. For example, a health system could employ a care coordinator whose time was otherwise not billable to the government or insurance company. Under value-based reimbursement, a system should do this if it thought the coordinator would achieve the same or better outcomes of care but at a lower cost. This is the power of aligned incentives.
Said simply, value-based reimbursement enables use of better pathways to make care more affordable. And, many health policy experts believe in the future that most payment will be value-based reimbursement.
Lee Health has been developing its expertise with value-based reimbursement with its Medicare Next Gen ACO, Medicare Advantage and Medicaid population health management programs. Lee Health should continue mastering use of value-based reimbursement as a priority.
Mergers, Acquisitions and Affiliations
As noted above, scale matters. There are other not-for-profit health providers in Southwest Florida whose performance is likely to be challenged over the next few years. These include NCH in Collier County and Bayfront in Charlotte County. Their challenges could come from competitors or, alternatively, because of federal or state action making operating a smaller provider difficult.
These providers are mission-driven like Lee Health. Combining operations through mergers, acquisitions or affiliations could both help Lee Health and allow these providers to continue to serve their communities. There should be economy of scale benefits. There may be opportunities for improved quality of care and for workforce development, too.
Pursuing these combinations with providers located outside of Lee County will likely require legislative and regulatory help.
There are also may opportunities beyond hospitals worthy of review including physician practices, urgent care centers and post-acute providers. Same principals apply.
Social Determinants of Health
In many ways, hospitals with their physicians are repair shops. They mostly intervene when parts of our bodies begin to fail. Some preventive services are provided like immunizations and selected medications, but mostly their job is to fix what isn’t working right. Happily, doctors and hospitals do their job well, as evidenced by the high quality of our lives and our increasing life expectancy.
There has been for a long time, keen awareness of the power of public health in keeping us well. Public health is deemed by some to be more powerful in keeping us well than usual doctor provided medical care. We take for granted public health interventions like clean water, appropriate sewage treatment, food, cosmetics, pesticide and drug safety, seat belts, bicycle and motorcycle helmets, and of course, immunizations. Imagine how we would fare in their absence.
There is growing acceptance of other important interventions that if used would help to maintain wellness and to forestall downstream health issues. Quality of life and life expectancy would be improved. Affordability is enhanced, too.
Often included as target opportunities are nutrition, physical activity and weight. These focus areas were referenced in the Community Health Improvement Plan. Through its Lifestyle Centers, Lee Health has made inroads here. Working in concert with government, agencies and employers, the effort should continue.
In the past few months there has been an increase in awareness and concern about social injustice. Most of the attention has been devoted to public safety. There is however a similar story regarding health care. Generally, minorities and people of color have a different health and medical care experience than members of the majority. Further, their outcomes of care are worse. Life expectancies are shorter and there is more chronic disease.
The absence of health equity is driven by a variety of factors, with the health care system being only one piece. Other factors often cited are economic stability and an individual’s environment including safety, educational opportunities, food availability and community.
Lee Health alone isn’t resourced to address this scope. More importantly, finding solutions, to the extent it is possible, necessarily involves many, many stakeholders.
Consistent with its mission, Lee Health should signal its willingness to do more here as an analyst, consensus builder and advocate, but also selectively as a leader. The Lee Community Health FQHC-Look Alike Centers represent an excellent beginning.