HEALTH CARE

Crawford handles the company's self-funded health plan, covering 2,300 employees and their dependents. The company's total health care costs run more than $3 million a year. To help him when he's negotiating contracts with two area hospitals, Crawford turns to data gathered by the Virginia Health Information, a Richmond-based organization that measures hospital performance. The VHI data "all gets filtered the same way and comes out in the same format," Crawford says, and having comparable data gives him negotiating leverage.

"Years ago, when someone said they were going to the hospital, they meant the one in the community," says Wayne Davis, spokesman for Augusta Medical Center. "But now there are considerations such as perceived quality, access, and cost that go into the choice. We have to do everything as well as we can."

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The market-driven approach is relatively new to health care. While in many businesses, that approach produces winners and losers, it's more difficult to gauge whether that will occur in health care. "Centers of excellence" are emerging for complex, high-cost procedures, but most hospitals still focus on doing a good job of providing the full spectrum of acute care.

Right now, there is no conclusive way to identify "centers of excellence," says Ramesh Shukla, a professor of health administration at VCU. "So far we've been able to provide good data on efficiency and productivity. But quality is the other side of the coin."

Shukla and VHI are working together to gather and test medical outcome data that takes into consideration the severity of patients' conditions. It's impossible to adjust the outcome statistics for all variables in each case, but hospitals generally expend more resources on the patients who are the sickest when they arrive.

Another group trying to evaluate health care outcomes has wrestled with the same issue. The Virginia Health Quality Center (VHQC) has been gathering data on quality for 14 years, says medical director Sallie S. Cook. The VHQC studies the quality of care from several viewpoints, such as whether the care is given in the right setting -- a nursing home vs. a rehabilitation center, for example. But it's the "clinical factors" -- such as patient condition and how the doctors respond -- that are tough to measure. "That's where our business becomes very interesting," says Cook, who is a medical doctor.

Interesting, but also confounding for purchasers of health care. That's why VHQC is working with business coalitions, such as the Blue Ridge Regional Health Care Coalition headquartered in Roanoke, to develop a community-based health improvement program. Hospitals, physicians and employers in the community are devising local standards of care for common workers' compensation complaints, such as lower back pain and carpal tunnel syndrome. Similar efforts in other parts of the country have shown that standard treatment protocols for such conditions save money and improve quality.

VHQC Executive Director Joy Hogan Rozman says her organization also can analyze different insurance plans to see how they treat a specific disease, such as diabetes. "Then businesses can make a value-based purchasing decision. Just giving someone raw data or gross data (such as mortality rates alone) does not give you good information on the quality of care rendered by the hospital," she says.

However, using data that was preliminarily adjusted for acuity by VHI, Virginia Business has identified seven hospitals in the state whose lengths of stay, charges and mortality rates were lower than expected in a number of service lines. All seven of the hospitals and some of their regional "centers of excellence" are featured in this story.

VHI representatives say they're not finished refining the data, though. They plan to work with researchers and hospitals during the next year to further validate and evaluate the information to determine which differences are statistically significant.

Ultimately the data can be used to identify regional centers of excellence with lower costs and better outcomes for procedures that require special facilities and staff, says VHI Executive Director Michael Lundberg. "Health care centers may not be unlike businesses that find they excel by specializing in certain areas," he says. "They may find that all parties benefit from the experience and expertise gained when a service is provided frequently."

For example, the University of Virginia Health Sciences Center has an excellent reputation for its neurology and cardiology departments. Its neurology department handled 2,601 cases in 1997 -- the most in the state, according to VHI. Its mortality rate for those cases was 32 percent lower than expected, while charges were 15 percent lower.

The hospital handled 4,513 cardiology cases in 1997 and had charges 26 percent lower than expected, according to VHI. Its mortality and length-of-stay rates were 17 percent and 10 percent lower, respectively.

Part of the reason for its success is that it is a teaching hospital, says Dr. Robert W. Cantrell, vice president of the center and CEO of U.Va. Health Systems. "Not only do they deliver outstanding medical care, but there's a phenomenal amount of leading-edge research and teaching going on," he says. "They are taking that research and applying it. Also, residents are always watching and asking, 'Why?'"

U.Va.'s neurology department has the lowest length of stay and cost per day in the country, says Fred Wooten, department chairman. Its status as a national leader in the effects of stroke research and treatment has been evolving for 12 years. When a new clot-busting drug became available, U.Va. worked on tests of the drug, which helped its stroke team become even more effective with early intervention.

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Improving the quality of care in a hospital doesn't necessarily mean spending a lot of money or even adding new departments. Sometimes it's as simple as cooperating with other providers.

One month after opening its new 255-bed facility in Fishersville, Augusta Medical Center teamed up with U.Va. to add a cardiac catheterization lab. U.Va. had already been providing that service to Augusta patients, but the university hospital realized that these patients weren't too happy about driving over Afton Mountain to gain access to the procedure. So U.Va. now staffs the Augusta lab, and the success of that project has led to similar arrangements for a pain clinic, improved plastic surgery and better services for ear, nose and throat patients.

The collaboration has worked so well that the hospitals have formalized these arrangements through VaLiance, a corporation representing an alliance between Augusta, U.Va., Rockingham Memorial Hospital in Harrisonburg and Stonewall Jackson Hospital in Lexing-ton. All four institutions have three members on the board of VaLiance, which works out ways to improve health care in each community.

And sometimes less is more. In the case of Augusta Medical Center, that meant closing community hospitals in Waynesboro and Staunton and opening the Fishersville facility in 1994. "The advantages of the merger have been proven," says Kathleen B. Heatwole, vice president of planning and development. "There is reduced duplication of services, equipment and staff; the ability to add new services and improve accessibility for our communities; the ability to attract new physicians and staff; and flexibility of design to focus efforts in line with developing trends, such as increased outpatient services."

And sometimes more is more. Within the past six years, Mary Washington Hospital in Fredericksburg has added a cardiac-care facility and a neonatal intensive-care unit. Before that, patients who needed those services were stabilized and transferred to Richmond, Charlottesville or Northern Virginia, all about an hour away. "Fredericksburg has changed," Rossiter says, "and that change demanded -- and could support -- more services."

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Prevention, early intervention and thorough follow-up are clear ways to cut health care costs while improving quality, and in recent years these types of programs have grown.

Mary Washington Hospital, for example, began a diabetes management program five years ago, and now its nurses counsel 1,200 patients a year, says program director Jane W. Schultz. A diabetes educator starts patients off with a two-hour session and then three half-hour, follow-up sessions.

Lengths of stay for endocrinology patients at Mary Washington were 9 percent lower than expected in 1997, according to VHI data. Charges were 12 percent lower.

Schultz credits education for reducing hospital admissions and lengths of stay. Half of the 600 outpatients the program helps each year are newly diagnosed diabetics, she says. "We're catching people early and teaching them skills to avoid hospitalization. About 30 percent of the patients we see each month have blood-glucose levels high enough to qualify for admission, but we're able to help them get control of blood-glucose levels quickly through outpatient services."

Valley Health Center, the parent corporation of Winchester Medical Center, has a similar intervention effort for diabetic patients. An estimated 43,000 people in the health system's service area have some type of diabetes, "but half don't know it," says Ann S. Pollard, director of the diabetes management program.

Supplementing an established program with local physician input, Valley Health has developed protocols to follow with diabetic patients. On particular days, nurses and dietitians from the diabetes management program go into the offices of endocrinologists, internal medicine specialists and family physicians. They meet with the patients first to obtain preliminary information and to make sure the proper tests are being done. "That makes the physician visit more effective and more focused. Then we follow up and continue to work with the patients on the phone," she says.

Keeping patients out of the hospital is one part of the equation; discharging them sooner is another. Shorter lengths of stay lower inpatient costs, but that can be a double-edged sword. If the motivation for discharging patients sooner is seen as financial, there can be a backlash. That's what happened to "drive-through deliveries."

However, with appropriate community-based services, patients can be sent home once they no longer need acute care. That's part of the systemic shift from inpatient services to a broader health network that promotes wellness. Health care organizations that own hospitals, hospices, home health agencies, outpatient clinics, rehabilitation facilities and nursing homes can easily move patients to the appropriate level of care within the organization. Case managers, often nurses who see the patient through the entire process, provide continuity.

A good example is Martha Jefferson Hospital's approach to orthopedic procedures in Charlottesville. Ron Cottrell, vice president of planning and marketing, says preparations for surgery and recuperation start early. The department has developed a notebook explaining each procedure. Patients attend a two-hour class to learn what to expect before and after surgery and to discuss pain management.

"An occupational therapist comes in and talks about adaptive equipment, dressing, bathing, car transfers and spends about 30 minutes with patients and families. They register for hospital admission, get their nursing assessment and blood work if the surgery is scheduled within 10 days of the class," says Kathy Nicely, an orthopedic case manager.

"Before surgery, a physical therapist goes to their home to do a home assessment," Cottrell says. The therapist points out safety issues, like negotiating steps, and takes note of any special equipment that may be needed, such as a bedside commode. He also provides practical tips, such as putting food and water within reach.

"The day they come in, we are already managing the discharge process," Cottrell says. "It has benefited the patient ... in terms of satisfaction, reduced length of stay, and managing cost more effectively."

The hospital's performance in orthopedics in 1997 was outstanding, according to VHI data. Patient lengths of stay were 29 percent lower than expected and charges were 46 percent lower.

Coordinating care is also a central theme at Winchester Medical Center. "Case management starts from the time the patient enters the hospital," and continues until the patient hooks up with the home-health community, says Terry L. Sinclair, vice president of medical affairs for Valley Health Center. "You can't simply move out patients without providing for proper care after discharge."

Betsey Lewis Snow, executive director of women and children's services for Valley Health System, says nurse case managers work with every obstetrical inpatient to determine whether she's at high risk after discharge. If the patient could benefit from parenting classes or financial assistance, her case manager and physician direct her to the appropriate community agencies.

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Obstetrics is one of those specialties where the patients' ideas about quality aren't necessarily expressed in statistics about outcomes, costs or lengths of stay.

The obstetrics department at Sentara Leigh Hospital attracts patients by offering a home-like birthing experience. Maternity rooms are large, and they are decorated in burgundy and gray with oak floors, rocking chairs and soft lighting. Sentara Leigh also is the only hospital in south Hampton Roads that allows mothers to stay in the same room throughout labor, delivery, recovery and postpartum care. In 1997, the hospital's obstetrical charges were 20 percent lower than expected.

About 135 mothers a month deliver babies at Sentara Leigh, up from 115 to 120 births per month earlier this year. And they're apparently bypassing other hospitals on the way to Sentara Leigh. Pam Robertson, director of Women's Health for Sentara Southside Hospitals, says Sentara Leigh's obstetrics patients come from a 15-mile radius. "We were a little surprised to find that people would drive farther for what they see as the ideal obstetrical experience," she says. Except for Sentara Norfolk General, which is a regional referral center for high-risk deliveries, the other two Sentara hospitals in south Hampton Roads draw most of their patients from only a five-mile radius.

At Rockingham Memorial Hospital, continuity of care from early pregnancy through delivery and postpartum adjustments is paying off, says Teresa Boschart-Yoder, director of the hospital's Family BirthPlace. Pregnant women take child-birth classes and get acquainted with the obstetrics department before delivery. And two to five days after discharge, a family-care nurse makes a home visit, completes a physical on mother and baby and talks to the new parents about adjustments or problems. "It's a better model because parents can get answers to real struggles once they've taken the baby home," say Boschart-Yoder. Women who have had several babies in other places send us letters saying they learned more about taking care of their baby here than they did from all their other experiences combined."

Will that kind of customer satisfaction ever be reflected in qualitative hospital data? Absolutely, says Lundberg at VHI. And when health care researchers develop more sophisticated ways of measuring hospital performance, that will give both businesses and hospitals a better handle on what to do next, he says. And businesses of all sizes -- not just those large enough to try to crunch the numbers themselves -- will benefit.

Crawford, Pulaski's purchasing point man, says using such data has become a fact of doing business. "It's like buying any other thing for the corporation. If the information is there, you have to look at it in making your decision."

Sally Kirby Hartman and Kathleen Phalen contributed information to this story.

© DECEMBER 1998, VIRGINIA BUSINESS MAGAZINE