macro-economic healthcare...

MACRO-ECONOMIC HEALTHCARE TRENDSPeter L. Bardwell, FAIA, FACHA

First, an apology . . .

© 2017 Peter L. Bardwell / A. Ray Pentecost

This will require a pace similar to “3000 Years of Art” presented in less than 3 minutes, thanks to Mason Williams and the Smothers Brothers in 1968

http://www.youtube.com/watch?v=2ibWm96aoPQ

http://www.youtube.com/watch?v=2ibWm96aoPQ

But this is all available to you as a PDF, so please don’t worry about taking notes . . .

In summary . . .

Catalysts for Change

• Technology• Increasing emphasis on patient safety• Shortages of key staff• Nursing shortage: emphasis on

productivity and nurse satisfaction• Return on investment

Catalysts for Change

• Regulatory initiatives • Reimbursement• Healing environment: family centered care• Planning for the unforeseen: clinical

change, new diseases, etc.

Surgical Suite and Emergency Department Design: Universal Models for Future Flexibility

Joan L. Saba, AIA, FACHAPeter L. Bardwell, FAIA, FACHA

March 8, 2005

2005 ASHE PDC, Nashville, TN

Fortunately, some of us are very good at predicting the future . . .

So, if predicting the future is a challenge --- where are we today?

•Shift of payments from volume to value

•Heightened visibility for quality, safety, costs, and patient experience

•Responsibility for population health management

•Increased financial penalties

ACA Compliance:

•Shrinking reimbursements by Medicare

•Reductions in state Medicaid funding

•Pressure by insurers for deeper discounts

•Increased tech and drug costs

•1 in 3 physicians elected to become a hospital employee

Other Challenges:

“While Congress implements its repeal, hospitals are left to navigate in uncertain waters.

“For hospital boards and management, the paralysis of inaction is a bigger risk than proactive pursuit of initiatives that are imperatives, even as the dust settles.

“While it’s sensible to proceed deliberately with major capital projects and operational endeavors for which clear near-term opportunity is discernible, the punch list for hospital leadership teams should necessarily include . . . “

Paul Keckley (continued)

“Shared risk arrangements with private insurers:

In all likelihood, value-based payment programs like bundled payments will continue. They save money for payers and force providers to coordinate care more effectively. The new administration is likely to suspend mandatory participation in bundles but encourage them voluntarily as a mechanism for stimulating competition. They’re not going away.”


“Accelerated cost reduction:

Every opportunity to reduce fixed and operating costs should be on the table, with no sacred cows. Outsourcing, disposition of nonearning assets (i.e. parking decks, back office facilities), job sharing, the supply chain, the revenue cycle, lower costs of capital, compensation, clinical program rationalization and much more need to be considered. The key is this: Acceleration of cost reduction is necessary as costs goes up, margins go down and the ranks of the uninsured swell.”


“Physician leadership:

Lowering costs, improving quality and managing patient experiences is the trifecta upon which competition between hospitals will be based. To achieve this triple aim, clinical processes must be led by clinicians skillful in leadership, process improvement, information, financial management and decision-making. Clinical skillfulness is table stakes.”


“Access to efficient capital and cash flow:

Access to capital at attractive rates and efficient use through cash management and off–balance sheet leverage arrangements are vital to the hospital business office of tomorrow. As high-deductible health plans become dominant, revenue cycle activities, whether internal or outsourced, that use sophisticated analytics to support cash flow management will be table stakes. The treasury and business office functions of the future are decidedly more complicated than those of the past.”


“Enterprise growth:

The scale and scope of services necessary to operate in the "new normal” require competencies in insurance, post-acute care, retail, telemedicine, digital health and more. The end game is not short-term consolidation of hospitals and hospitals: It is systems of health that serve individuals in their homes, workplaces and schools, not just clinics and facilities.”


“Workforce productivity:

Hospitals are labor-intensive, and our patients are sicker and more demanding than ever. Clinical innovations and the need for new services stress our workforces. It’s a people business, and our people are keys to our success.”


First, let’s look at some key precepts . . .

The Affordable Care Act (Obamacare) is only one among over a dozen forces that affect our present and future healthcare delivery models and the facilities that we create in support of those models, and that’s the focus of today’s discussion

The Affordable Care Act is INSURANCE reform; not HEALTHCARE reform, although this insurance reform drives responses like the emphasis on population health and consumerism

Insurers and healthcare providers hate uncertainty and tend to pull back for months or years until they have a sense of where the market is headed

KEY PRECEPTS (aka Peter’s “Alternative Facts”)

In most scenarios, change will continue to be gradual. Barring a financial meltdown or even more dramatic political upheaval, the broad trends that we identified over a decade ago will be the trends of the next decade

Follow the money. The government (both Federal and State), insurers, providers, and consumers will rarely do “the right thing” unless there’s a financial incentive

Lastly, we need to distinguish TRENDS from FADS. An aging population is a trend; fireplaces in hospital lobbies is a fad

KEY PRECEPTS (aka Peter’s “Alternative Facts”)

The future isn’t what it used to be . . . .

- Paul Valery (1871 -1945)

According to the Library of Congress , this painting by Harry Grant Dart was used as the cover for an issue of All Story magazine between 1900 and 1910.

The most revolutionary aspect of this image may be the depiction of a woman at the wheel. Women couldn't even vote in the UnitedStates until the Nineteenth Amendment was ratified in 1920.

http://paleo-future.blogspot.com/search/label/1900s

http://paleo-future.blogspot.com/search/label/1900s

The take-away . . .

When predicting the future . . .

• Some of our intended points turn out to be wrong, and

• Some of our unintended points turn out to be right!

A recent conversation . . .

A recent conversation . . .. . . with a friend, who’s a former hospital CEO

I say “former hospital CEO” because he’s now a system Sr. VP

• And in that new role, he’s now working with clinical service lines over the system’s 5 hospitals and dozens of additional settings, all becoming linked by electronic medical records




• Concurrent with that, the health system has just announced a mega-partnership of 6 systems representing 40 hospitals and several hundred health facilities across the state





• And notably, his former CEO role was with a financially-successful, yet relatively small, independent health system that elected 8 years go to merge with the larger health system for which he’s a Sr. VP

. . . and on the personal side, he was relating his recent total hip replacement surgery

• And for that total hip, his total hospital stay was . . . 12 hours . . . before returning home . . . and walking the following day

• And to make that happen, he selected his surgeon based upon that desire to not have a hospital stay (because he knows that bad things can happen as an inpatient)

So --- why is this important --- and how does it all relate to healthcare trends and related design trends?



• And notably, his former CEO role was with a financially-successful, yet relatively small, independent health system that elected 8 years go to merge with the larger health system for which he’s a Sr. VP

• And for that total hip, his total hospital stay was . . . 12 hours . . . before returning home . . . and walking the following day

• And to make that happen, he selected his surgeon based upon that desire to not have a hospital stay (because he knows that bad things can happen as an inpatient)

First, emphasis on some key words . . .

Healthcare Trends Impact on Design and Development

1. Consolidation through mergers and acquisitions:a. the big get

bigger and the small get smaller

b. the day of the small independenthospital is over

A. You may have had a wonderful relationship with a given facility and its leadership, but that can disappear in an instant due to consolidation






B. And one of the driving goals of that consolidation is standardization of the care environment across multiple facilities. The sizes of rooms (and the location of soap dispensers) may likely all be dictated by a central facilities group at the system level







C. And the project that you’re marketing or for which you’ve been selected is likely competing for funding and support by individuals in another city for whom this is only one of many requests for limited system resources





A. You, as designers, contractors, suppliers may have had a wonderful relationship with a given facility and its leadership, but that can disappear in an instant due to consolidation


C. And the project that you’re marketing or for which you’ve been selected is likely competing for funding and support by individuals in another city for whom this is only one of many requests for limited system resources


2. The “health continuum”a. continued shift

from inpatient beds; and

b. focus on population health*

A. The traditional inpatient setting, albeit important, becomes but one end of a wide “health continuum” from illness care to health maintenance






B. Inpatient facilities will exist as “a last resort”,focusing on traumatic injury and stabilization of those with multiple chronic health issues







C. Inpatient bed-related projects, at best, will be replacements







C. Inpatient bed-related projects, at best, will be replacements

*Notably, while “population health” is a noble goal, until financial incentives catch up with noble goals, this concept may remain largely aspirational for the near future. The concept, nevertheless, is both framing and resulting from consumer demand --- and the marketplace may respond more quickly than in the past.


3. Consumer empowerment

A. Tech-savvy boomers will demand a “retail” experience with online selections, easy access, and no-waiting




B. The physician-centric era is over, and boomers will be very selective of the care-giver and setting --- which may be a Nurse Practitioner at Target; not a physician in a hospital ED.*




B. The physician-centric era is over, and boomers will be very selective of the care-giver and setting --- which may be a Nurse Practitioner at Target; not a physician in a hospital ED.*

*And notably, my friend in the aforementioned story was very assertive in selecting a surgeon who had experience with lesser invasive surgery for a total hip and who was comfortable with the proposed post-operative care process --- per “Continued shift from inpatient beds” on the prior slide!


4. Standardization A. Not only are room designs becoming standardized; construction components are being standardized and fabricated off-site.



B. Had my friend become an inpatient, he would have likely been placed in a 3-year-old bed tower in which all inpatient rooms were fabricated off-site and trucked and lifted into place.



B. Had my friend become an inpatient, he would have likely been placed in a 3-year-old bed tower in which all inpatient rooms were fabricated off-site and trucked and lifted into place.

(But he didn’t become an inpatient, did he . . . ?)


5. Non-building capital priorities

A. As my friend noted, their 5 hospitals and multiple additional care settings are well-immersed in implementing a consolidated electronic medical record system.


5. Non-building capital priorities

A. As my friend noted, their 5 hospitals and multiple additional care settings are well-immersed in implementing a consolidated electronic medical record system.

B. And as with many health systems around the nation, EMR launches are consuming capital dollars at rates that can be far higher than facility-related projects. Bluntly stated, building projects can be low in the pecking order for many health systems.

• First, distinguish trends from fads. Standardization of rooms and components is a trend. A gently-curved bed tower facade is a fad.

• Second, look to the past for those ideas that remain timeless --- because health facilities designed a decade or more ago have already stood the test of time and their successes can speak volumes.

• Third, observe what other countries and cultures are doing. (More on that in a moment)

• Fourth, look outside healthcare altogether. As already noted, consumers expect healthcare environments to exhibit the best of elements and experiences of retail, lodging, and other markets.

Key points . . .

Learning from other cultures . . .

Learning from other cultures . . .A key example of observing what other countries and cultures are doing --- often far better than we’re doing in America --- is Khoo Teck Puat Hospital in Singapore, a 590-bed facility that opened in 2010 and that features many of the population health initiatives that we’re only beginning to address in America.

• Integrated campus: multiple levels of care ranging from skilled nursing to tertiary care; supplemented by a community-outreach Aging-in-Place program

• Effective incorporation of natural light, natural vegetation, and natural ventilation

Learning from other cultures . . .• Strong encouragement to use stairs versus elevators both for

staff and for visitors by making stairs open, accessible, and inviting

• Integrated with the communityo Roof-top vegetable garden accessible to the communityo Upscale food court with two-tiered pricing favoring healthy

choiceso Exercise apparatus available to the community disguised as

“fun” activities

High tech . . .

. . . and high touch

Solar PanelsCommunity Garden (on the roof)

Learning from other cultures . . .• Strong encouragement to use stairs versus elevators both for

staff and for visitors by making stairs open, accessible, and inviting

• Integrated with the communityo Roof-top vegetable garden accessible to the communityo Upscale food court with two-tiered pricing favoring

healthy choiceso Exercise apparatus available to the community disguised as

“fun” activities

Learning from the past . . .

Learning from the past . . .Project Goals

• Focus a hospital on wellness as integral part of a new planned community’s life

• Express human values & community values• Influence change elsewhere• Be dynamic and flexible• Showcase state-of-the art technologies

Learning from the past . . .Project Goals (as stated during early planning in the early 1990s)

• Focus a hospital on wellness as integral part of new planned community’s life

• Express human values & community values• Influence change elsewhere• Be dynamic and flexible• Showcase state-of –the art technologies

Learning from the past . . .A key example of learning from the past is Celebration Health, near Orlando, which opened in 1998 with a bold vision to redefine American healthcare delivery.

As planning and design started over 20 years ago, fundamental precepts mirrored those identified in today’s panel discussion ---and importantly, have remained timeless and have yielded tremendous success over a period of 2 decades of industry change.


Celebration Health “Firsts” . . .• “universal” patient room• “zoning” of the patient room into

patient/caregiver/family zones• “on-stage / off-stage” zoning of activities and

circulation


Celebration Health “Firsts” . . .• full, planned integration of the hospital into

the community --- an example of which is the 100,000 SF community fitness center• which is contained within the hospital and

is accessed only through the hospital in order to send a message to the community that this building is as much about health maintenance as it is illness care.


Again, the aforementioned were “firsts” 20 years ago --- but the trends that those firsts represented are timeless.

They’re as applicable today as they were then.

So, maybe the future is what it used to be . . . !

So, a very quick recap . . .

HOW 10 FORCESARE CHANGING

HEALTHCARE DESIGN** An update by the authors of “The Future Is Now”, published in the

March 2011 issue of Health Facilities Management magazine

Peter L. Bardwell, FAIA, FACHA2017 Board of the AIA Academy of Architecture for Health2013 President of the American College of Healthcare Architects2012 President AAH Foundation2008 President of the AIA Academy of Architecture for Health

with great thanks to my co-author and colleague:

A. Ray Pentecost III, DrPH, FAIA, FACHA2018 President of the American College of Healthcare Architects2013 President of the International Academy for Design and Health2009 President of the AIA Academy of Architecture for Health

The Future Is Now --- Redux

The genesis of this presentation dates to late 2010 when Peter Bardwell and Ray Pentecost were asked by Health Facilities Management magazine to write an article for the March 2011 issue on behalf of the American College of Healthcare Architects (ACHA) on the impact of the Affordable Care Act (ACA; widely now known as “ObamaCare”) on facility design.

It quickly became clear that: 1) the political course of the ACA at that time was evolving too rapidly to draw definitive conclusions; and 2) more importantly, it became clear that there were far greater issues creating an impact on healthcare design than the political outcome of the ACA.

This “second generation” of the study looks back over the subsequent 7 years and reflects on the changes --- and constants --- during that period.

Presentation Background

. . . shaping trends to follow

10 Forces Influencing the IndustryPart One


Alarming fall in reimbursements

Continuing downward pressure on Medicare reimbursement will likely narrow operating margins.

Eventually these margins may prove inadequate for a break-even operation.

Pressure will exist for commercial payors to lower rates to the Medicare standard.

As a result of increasingly scarce excess revenues, capital may be harder to access, or even unavailable.

“At Medicare rates (only), hospitals would be challenged to remain open” Source: Ken Kaufman, AAH/ACHA SLS, July 2010

In 2011, we concluded that, “The status quo is unsustainable, irrespective of the final political refinement of the ACA.”

And what we thought --- is still the law.

March 2011 Report September 2017 Update

1Force


Alarming fall in reimbursements

May 9, 2013, 2:46pm EDT

Health-care providers to see big impact from reimbursement cuts

1Force

“In the latest [Premier] survey, 48 percent of the respondents anticipate that reimbursement cuts will have the greatest impact on their business during the year ahead.”

“ . . . Medicare reimbursements already fall short of what it costs to provide care. On average, inpatient reimbursements fall 5.8 percent shy of actual costs, while outpatient procedures fall 10 percent short . . .”


Pennsylvania’s hospitals shed 3,900 jobs in the year ending in February 2014, signaling financial stress in the health-care market, a new survey found.

In addition, the Hospital & Healthsystem Association of Pennsylvania survey of acute-care facilities found:

• 67 percent have or plan to freeze hiring

• 51 percent have or plan to delay or cancel building renovation projects

• 49 percent have or plan to furlough staff

Alarming fall in reimbursements1Force


Focus on transparency and quality

Again, what we thought --- continues to be the law.

And --- consumer access to information is growing at a rapid pace.


2Force

Expect payment disincentives for preventable hospital admissions and readmissions, as well as for avoidable adverse health outcomes, the so-called “never events” list.

This will probably lead to a reassessment and reinvention of the overall patient process and experience and suggests continuing downward pressure for an average length of stay(ALOS) to be reduced to generally-accepted best practices.


Focus on transparency and quality2Force

“Because consumers have been slow to make use of health care quality reports, it remains to be seen if price information will be enough of a hook to engage them in comparison shopping for care.”

The Commonwealth Fund, Quality Matters Health Care Price Transparency: Can It Promote High-Value Care?, April/May 2012


Focus on transparency and quality2Force

Gary Kaplan, Virginia Mason Medical Center, July 2013


Importance of information technologies

IT is a blended world Information technologies Healthcare technologies Building technologies

PLUS Merged provider systems

IT has a new priority: quality Historically about billing and EMR Conversion is a challenge

IT requirements GROWING

The era of “Big Data”


3Force

“Meaningful use” of EHR predict their greater use in measuring performance in the healthcare system.

The patient-centered medical home (PCMH) model uses EHRs to link primary care with the remainder of an integrated care system.

Just as electronic delivery of information, “eHealth”, permits a transition from paper-based records to the EHR, there is growing evidence that “mHealth” will supersede it using mobile communication devices, such as mobile phones and PDAs, for health services and information.



Entire Library of Congress 20 terabytes

Kaiser Permanente IT 9 companies, 27 divisions (equivalent) 453 facilities w/ 203,000 desktops 173,000 MDs and employees 4,700 terabytes of information, and increasing

From a 2008 presentation to the ACGME by Malcolm/ Lewis on the Kaiser Permanente IT

3Force

Source: 1 Ms Christine Malcolm, presentation to 2010 AIA-AAH/ ACHA Summer Leadership Summit


Importance of information technologies3Force



Not directly addressed in our 2011 report

The Law of Disruption: social, political, and economic systems change incrementally, but technology changes exponentially.

Source: Larry Downes, Forbes, January 12, 2013

3Force

. . . and we’ll address the impact of this a little later . . .


Importance of information technologies3Force

. . . and many of these disruptive technologies will change everything . . .


Staffing shortages and reassignments

Hospitals need to staff up to handle millions of Americans gaining coverage under the Affordable Care Act Source: H&HN, June, 2013

A call by the Bipartisan Policy Center for a national approach to workforce planning Source: H&HN, March, 2013


4Force

There is a predicted shortage of nurses in all 50 states by 2015.

Physician shortages will likely be as widespread and potentially even more severe, especially in the near term.

These shortages, as well as those of other highly-skilled professionals, negatively impact care not only in hospitals but also in long term care, ambulatory care, and a broad range of other settings.


Staffing shortages and reassignments4Force

But is this really a crisis? Yes, the statistics are daunting,

but are we using the correct quantifiers?

“What would happen if . . .we looked for ways to change the ending without necessarily changing the facts?”

“Most estimates are based upon simple ratios . . .”

Perhaps we need to shift our thinking from the current paradigm of care management.

Matthew Weinstock, H&HN, April, 2013


Staffing shortages and reassignments

And . . . “The theory goes that with 32

million previously uninsured Americans joining the rolls of the insured, there will be a need for facilities to house physicians and services to treat them.

It’s a mistake, by the way, to believe these 32 million people haven’t been treated in the past.

Many have sought and received care in hospital emergency rooms, where federal law prohibits refusal of care on the basis of inability to pay.”

The core issue is really: Where care will be given, and By whom care will be given

4Force

Jean-Claude Saada, Facility Obsolescence – A Welcome Casualty of Health care Reform?


Migration of care away from the facility

Personal healthcare, e-health, virtual-health, home health, tele-health, m-health

Prospective medicine: Predictive Preventive Personalized Participatory Focused on pre-disease

Key question: is a facility needed to help an individual achieve health?

Source: RADM Bill Rowley, Clinical Medicine in 2038, Webinar 1/14/13


5Force

Just as eHealth and mHealth will permit more efficient delivery of care inside the hospital, they will perhaps be of greatest long-term impact outside the hospital.

The marketplace has grown accustomed to movement of primary care into retail settings.

Intel’s Digital Health Group leads a well-refined effort to provide viable “aging in place” settings.

The Garfield Center of the Kaiser Permanente organization is exploring the use of Wii™ micro-technologies.


Migration of care away from the facility5Force

Again, the core issue is really: Where care will

be given, and By whom care

will be given And do we have

greater value for a “retail” experience than the “Marcus Whelby” experience?


Wal-Mart in healthcare?• 4th largest pharmacy in US• 150 retail clinics (behind CVS and Walgreens)• Health insurance Sam’s Club• Health and Wellness: (2011)

11% Walmart 5% Sam’s Club

• Plan: health insurance exchange = ACCESS

Migration of care away from the facility5Force

“Patient visits to retail health clinics quadrupled between 2007 and 2009”Source: Walmart clinics, health insurance, sales plan shows retailer’s rising interest in health care business, by Jeffrey Young, The Huffington Post, 1/17/2013


Obsolescence and poor location of assets


6Force

The current supply of medical care beds are not where the projected demand for those beds will be in the coming decades.

But that’s presuming the current paradigm of care settings!

Bottom-ranking hospitals in a Consumer Reports quality survey cluster around metropolitan areas, suggesting that they face special challenges

Major urban medical

centers need to replace

aging assets dating to the 50s and 60s--- they have

no choice.


Obsolescence and poor location of assets6Force

There is a cost of doing

nothing.


Changing medical model

Personalized medicine has the potential to change the way that medicine is prescribed, and it could provide more targeted, efficient care with better outcomes for patients, ultimately leading to lower costs for everyone involved Source: Smart Business, January 2012

Elements of the Affordable Care Act function as a rezoning effort, allowing and encouraging development of new health care structures. Among these structures is the Patient-Centered Medical Home (PCMH). Source: S. Sanford, UW School of Law, November 2012

. . . and the impact of genomics


7Force

If all reimbursement (including commercial payors) went to the Medicare standard, many if not most hospitals couldn’t stay open.

Only a few of the largest systems would survive; others would be cannibalized or absorbed for volume to cover overhead and fixed costs.

The future of smaller(independent) organizations is uncertain and probably not viable. Therefore, the amount of capital investment in independent community hospitals will likely remain greatly diminished



Wal-Mart announced that employees who needed certain pricey surgeries would have the option of traveling to one of the six best hospitals in the country that specialize in those procedures.

A second element is hospital payments. Instead of the usual arrangement, where insurance companies reimburse providers à la carte for various services, the travel-surgery programs are based on a flat fee for all the care involved in a procedure.

7Force



Lowe’s --- with 200,000 covered individuals --- has a similar contractual relationship.

7Force

Kevin Vigilante, Booz/Allen/Hamilton, July 2013

What if your community’s largest employer were to bypass your organization --- and your (prior) direct competitor --- and send high value patients hundreds of miles away?


Greater emphasis on health vs. medicine

In the life cycle of public health eras, we have arrived at the one focused on health

Chronic diseases are a pandemic throughout the US

Chronic diseases are lifestyle diseases with 50% of risk factors modifiable

Emphasis on health/ quality outcomes compatible with fee-for-service?


8Force

The 3 risk factors of tobacco, activity, and diet will play increasing roles in the focus of the health care delivery system and of the facility response to that system.

Our children’s generation is the first in American history to have a shorter life expectancy due to obesity and related diseases.


8Force

Source: Breslow L., Health measurement in the third era of health, American Journal of Public Health , 2006:96:17-19.



Chronic diseases:

• 81% Hospital admissions

• 76% Physician visits

• 91% Prescriptions

• 75% Spending on healthcare ($2+ trillion)

• 96% Medicare spending (elderly)

• 84% Medicaid spending (poor)Source: Prevention and Wellness, Partnership to Fight Chronic Disease

8Force



Deaths from infectious diseases; maternal and

perinatal conditions; and nutritional deficiencies

combined are projected to decline by 3% over the

next 10 years. However, over the same period,

deaths due to chronic diseases are projected to

increase by 71%.Source: Global Risks 2010: A Global Risk Network Report, World Economic Forum, January 2010, p. 24.

Mortality: worldwide perspectives

8Force



8Force


Daily Medical Expenditures in the U.S.:

1.Heart Disease $501,000,000

2.Cancer $430,000,000

3.Digestive Disorders $337,000,000

4.Obesity $320,000,000

5.Diabetes $273,000,000Source: RAND corp./ US NIH 2000 (From the work of Mark Haynes, DC, Norfolk, VA, 2011.)

And DEMENTIA: $1,000,000,000Source: Ruth Bettelheim, America can’t afford to neglect dementia care, USA Today, March 16, 2011

In these 60 minutes, the U.S.

expenditure will be:

$119,208,332


8Force


If, with exercise: 1

Prevent 91% of cases, type 2 diabetes

Prevent 50% of all cases, heart disease

Prevent 50% of all stroke deaths

Reduce site specific cancers by 50-72%

What would happen to your facility . . ?1 Journal of Applied Physiology 2005


8Force


If, with exercise: 1

Rainer Hambrecht, MD German researcher:100 cardiac patients

After 1 year:50 patients exercise:

50 patients stents:

What would happen to your facility . . ?Source: Mike Evans, MD, video, 23 ½ hours: what is the single best thing we can do.

88% event free

70% event free


Demographics in the marketplace

Clinical manpower debates of supply and demand will add distribution and specialty to the assessment

Baby Boomers will dominate market behaviors and economic forces Technology competence Chronic disease burden for system

Consumers will wrestle with conflict of individual choice and group responsibility


9Force

Shortages of MDs and RNs, as well as those of other highly-skilled professionals, negatively impact care not only in hospitalsbut also in long term care, ambulatory care, and a broad range of other settings.


“At this point, more than 10,000 Baby Boomers are reaching the age of 65 every single day, and this will continue to happen for almost the next 20 years.”

Source: Michael Snyder, Do You Want to Scare a Baby Boomer?, Jan 17, 2013.

Boomers Situation: 25% of 46-64 yr. olds no

retirement savings 1 of 6 seniors below poverty 40 %: work “until they drop” 1991-2008, age 65-74,

bankruptcy rose 178% Medical bills big factor 60% 75% had health insurance

SS: $134 Trillion, next 75 yrs. Medicare: unfunded liability of

$38 Trillion, next 75 yrs., $328,404 every US household

Demographics in the marketplace9Force


9Force


Non-compliance/ Non-adherence

Health literacy:

• 33% patients marginal/ inadequate

• 42% misunderstood directions for meds

• 25% misunderstood schedule for follow-up

• 60% misunderstood informed consent

Source: Martin, Leslie R. et al, The challenge of patient adherence, Therapeutics and Clinical Risk Management, September 2005.


9Force


Non-compliance/ Non-adherence

Failure to comply with treatment regimens

• Up to 40% failure rates

• Up to 70% failure rates if lifestyle/ habit changes

Source: Martin, Leslie R. et al, The challenge of patient adherence, Therapeutics and Clinical Risk Management, September 2005.


User behavior w/ mobile health apps

After 1 day: 38% stop using the app

After 1 week: 50% stop using the app

After 6 months: 90% stop using the app

Source: Yossi Bahagon, MD, Clalit Health Services, Israel, presentation for the International Academy for Design and Health, Helsinki, Finland, September 20, 2012

9Force



Healthcare linkage to national security

Q What will it take for the public to take responsibility for their own health, to get involved in healthy behavior in order to reduce the demand for medical care?

A They must first understand that their individual freedom is at stake!

Source: Ken Krakaur, Sr. Vice President, Sentara


10Force

All nations are vulnerable to one sector of the economy growing too big and causing economic instability.

In the US, some health economists believe the windowof imbalance is when any one sector reaches 20-25% of the GDP --- and healthcare as a percent of GDP is nearing 18%.


10Force

Source: National Health Expenditures, Centers for Medicare and Medicaid Services, Office of theActuary – projections include impacts of the Affordable Care Act



10Force

This situation is time sensitive:

Every nation has a different tipping point!From the work James Orlikoff, Orlikoff & Associates, Inc. and National Advisor on Governance and Leadership to the American Hospital Association


. . . resulting from the aforementioned forces

6 TrendsPart Two


. . . so what does this have to do with health facilities?. . . EVERYTHING


Trend 1: The “Health Continuum”

“The function of protecting

and developing health must rank even above that of restoring it when it is impaired.”

“Architecture for Health” no longer means designing a healthcare facility; it refers to a design continuum.

Hippocrates, Athens Business News,April, 375 BC

Disease Health

Hospitals Wellness Centers Home

When population health is the measure of success, a disease treatment system will no longer be sufficient.

Health facilities will need to address that full spectrum of care settings

FACILITY IMPLICATIONS


Trend 2: Focus on Outcomes, Health

“Apple taught us

that the most important part of a

relationship was not the component strength – it

was the overall

experience.”

Priority shifts Quantity → Quality Medicine → Health New construction → Asset life extension

Dr. Gerald Potzsch, Philips Healthcare NordicPresentation 9/20/2012 in Helsinki, FinlandInternational Academy for Design and Health

Operational efficiency Clinical staff to their competence limit Facilities only when necessary

Systems operational modeling Contributing to quality (stats)



Trend 3: Personal Accountability

“You can lead a horse to water, but

you can’t make him

drink. Really? You can feed him

salt.”

Estimates have shown: 70+% of cardiovascular disease deaths 40% of chronic respiratory disease deaths 34% of cancer deaths 50% of all chronic disease deaths are attributable to a small number of known

modifiable risk factors.

Dr. Howard Hendricks, Dallas Theological Seminary, Seven Lessons of the Teacher

Accountability interface Incorporating lower utilization Repurposing as “salt” (when?) Catering to Boomer technology (in)competence


Source: Dele O Abegunde, Colin D Mathers, Taghreed Adam, Monica Ortegon, Kathleen Strong, The Burden and Costs of Chronic Diseases in Low-income and Middle-income countries, The Lancet, Vol. 370, December 8, 2007, p. 1937.


Trend 4: New Roles & Partnerships

“Most Architects

[Design Professionals]probably do not think of themselves as health

professionals – but they

should, because they

are.”

The new Facilities Manager From the Boiler room to the Board room

New relationship with the design community The FM conversation broadens: as integrator

of health systems and of diverse information

Richard Jackson, MD, MPH, HonAIA, UCLA School of Public Health

Performance vs. Prescriptive Reduced emphasis on facility name/ type Environments that support care (home?) and the

mission of better health



Trend 5: Continued Consolidation

Marks the end of the

independent community hospital ---with all its autonomy

and singular focus on its immediate community

Larger healthcare systems due to Mergers and acquisitions Capitation Bundling Economies of scale

50 systems in 10 years Shift toward retail: Are Wal-Mart, Target, and

Walgreens among those? Offering their own insurance exchange; portable

across the country

Pentecost and Bardwell, Health Facilities Management, March, 2011

The big get bigger and the small get smaller



Trend 6: Doing Even More with Less

Can we use this facility

for “x” use in the future ---or does “x” even need a

facility?

The end of “better, faster, cheaper”? That’s a dead-end; you’ve just backed your health system into a corner.

New Priorities Asset life extension Life-cycle cost vs. first-cost only Flexibility; anticipation of future adaptive re-

use Be sure that you’re asking the right question . . .

because questions that involve “better, faster, cheaper” may lead to the wrong answer.


10 Major Forces . . .. . . and 6 Major Trends Resulting from those Forces

Recap


10 Major Forces

Force 1: Alarming fall in reimbursementsForce 2: Focus on transparency and qualityForce 3: Impact of information and disruptive technologiesForce 4: Staffing shortages and reassignmentsForce 5: Migration of care away from the facilityForce 6: Obsolescence and poor location of assetsForce 7: Changing medical modelForce 8: Greater emphasis on health vs. medicineForce 9: Demographics in the marketplaceForce 10: Healthcare linkage to national security


6 Trends Resulting from those Forces

Trend 1: The “Health Continuum”Trend 2: Focus on Outcomes, HealthTrend 3: Personal AccountabilityTrend 4: New Roles & PartnershipsTrend 5: Continued ConsolidationTrend 6: Doing Even More with Less

© 2017 Peter L. Bardwell

Peter L. Bardwell, FAIA, FACHABARDWELL+associates, LLC2703 East Broad StreetColumbus, OH 43209

614-239-1639pbardwell@bardwellassociates.comwww.bardwellassociates.com

mailto:[email protected]

http://www.bardwellassociates.com/

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