As told to Matthew Weinstock
Benjamin Chu, M.D., has followed an atypical career path for both a doctor and hospital administrator. A primary care physician by training, he started his medical career in public health. During the past 20-plus years, he has run outpatient clinics, emergency departments, hospitals and health systems. He's moved between public health, academic centers and now to the nation's largest integrated health system, as group president, Southern California and Hawaii, Kaiser Foundation Hospitals and Health Plan. He's been a champion of performance improvement and systems reform for decades, always asking one critical question: What is best for the patient? In a wide-ranging interview with H&HN's Senior Editor Matthew Weinstock, Chu, the American Hospital Association's chair-elect, says it is time to "break away from the extreme fragmentation" that's limiting providers from truly providing the full continuum of care.
My earliest memories as a child were of being in the hospital. I had two bouts of rheumatic fever when I was 3 to 4 years old. I also had a mitral insufficiency condition — a heart valve leakage — that I had repaired when I was in my 30s. The old New York Infirmary on 15th Street, now part of the Beth Israel system, is where I was hospitalized. My first images were looking out of the hospital room onto a park right outside. The first toy I remember having was a stethoscope. My pediatrician gave me one to keep me occupied. It is a nice gift to have when you are sitting around bored in the hospital three months at a time.
My parents were immigrants from China and it's the immigrant dream for their kids to have a profession. Being a doctor was kind of an easy pathway. Growing up in Chinatown, there was never a lot of money around. In those immigrant communities, the whole focus was to try to make it in America. They were strong believers in the American dream. So, coming from that community and starting my medical career working in the public hospital system, growing up with people who actually used the public hospital system, those all had an influence.
If I think about the kinds of things that have made me successful, the kinds of strategies that I've used, I've always focused on what is the right thing for our patients. Being a patient at such a young age had a lot to do with that. I could see what worked and what didn't work. How did it make me feel? How did it make my mother feel? I could see the patient and family perspectives. So I always come back to, "Well, what would I want if I were the patient?" It's natural for me to think that this is part of the mission of health care and what we need to be doing in society. When I went into medicine, I always wanted to make sure that health care had its place in the community, a community of need as well as the larger society.
'I Can Fix It'
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When I finished my residency at Kings County Hospital [Center], I thought, "OK, now I'm going to go into cardiology." I was interested in all affairs of the heart. Then I looked around at the public hospital system, which was chronically underfunded, but incredibly mission-oriented. At the time, it wasn't really user friendly. You couldn't get a chart when you were seeing a patient. I can't tell you how many patients would come to me in the outpatient setting and all I'd have is a blank piece of paper.
I was faced with a choice: Am I going into cardiology, which would have taken me down the pathway of clinical care and probably a nice practice somewhere, or was I going to do something larger?
I decided that I couldn't stand how we were treating our patients in the outpatient setting. That's exactly how I felt, I just couldn't stand it. Instead of shutting my eyes to it and saying, "It is someone else's problem. I'm a single individual; I can't possibly do something about it," I said, "I can fix this." I was all of 30 at the time and you can say that when you are young. You have an ignorance of youth.
I talked my chairman of medicine into making me the director of the medical clinic, which had 60,000 patient visits a year. There were 120 interns and residents rotating through and there were probably 10 to 15 full-time attendings. The wait time to get an appointment, if you were not urgent, was two to three months. Of course, by the time that came around, you forgot that you had the appointment or you would have gone to the ER.
I wanted to fix the system on behalf of patients and we actually did a lot. There were a lot of work-arounds. We weren't going to get the medical records system to work functionally, but we got patients to the doctors who knew them. We got access down to a matter of weeks. We set up systems to get lab test results back reliably. We figured out ways to rationalize the system.
When you have a system that has a lot of dysfunction, the front-line staff are going to come at any changes with a lot of skepticism. So, one of the smartest things I did was deciding, a couple of weeks before actually starting the job, to do everybody else's job. I greeted the patients at registration. I fought for the medical charts. I made appointments. I called the doctors if they didn't show up. I worked with the interns and residents on care plans. I did the post-visit discussions with the patients. Those receptionists became my best friends and allies when we started down the path of trying to take out some of the dysfunction.
A Broader Perspective
I spent almost eight years at Kings County. Figuring out systems change is what launched me into my atypical physician career. When I was president of the New York City Health and Hospital Corp., I wanted our standards to be much more patient-focused and for us to be aware of how people perceive their care and whether it is actually effective. I went on this tear about access to care in the outpatient setting and being much more patient-centric. I set a goal that for primary care visits in all of our outpatient clinics, we were going to aim to take no more than one hour from the time a patient comes in to when they leave. Everyone thought I was totally loony. We brought in some tools; we did a lot of process mapping. We figured out where the dysfunction happens. We were right around that one hour limit when I left to come to Kaiser.
There was a lot of focus on operational improvement and process engineering, but also getting people to understand that if you are a patient coming in, the last thing you want to do is sit there and wait. We designed processes and inefficiencies into the system; we could design them out. I actually got very excited about the idea that the health care system could change.
No matter what I wanted to do, though, when it came to looking at the full continuum, there were financial implications; there were things that we couldn't afford to finance at a public hospital. At Kaiser, you have a system where all of the dollars, not just 20 or 30 percent, are prepaid. You can play in a lot of different spaces. Coming here was an incredible opportunity to try to help a system get to the point where we could demonstrate that there's a better way of doing things.
I think that my colleagues in the hospital world want that opportunity to broaden their perspective as well outside of the hospital walls; outside of just providing emergency care and outside of providing the best specialty care. They don't want to see the patients just in that time frame. Patients don't live in that time frame.
In the discussion that started at the AHA a few years ago around the Health for Life platform, and in discussions subsequent to that, people really understood that the fee-for-service world traps us. It limits us to think about the individual pieces. It limits us from working on a full continuum. When people get sick, we are going to do the best job we can to get them back on their feet, but there are larger issues surrounding how we keep them from getting sick in the first place.
When you look at the Health for Life framework, it talks a lot about coordination across the whole continuum; it talks about taking on the broader responsibilities in society for lifestyle changes, or at least taking on a role for pushing for better lifestyle choices. It talks about equity of care. Health for Life gets us thinking about where the U.S. health care system needs to go. I believe the AHA has shown incredible leadership in trying to push a framework that outlines how the system has to change. Hospitals in Pursuit of Excellence, for example, offers real substantive contributions to getting people the tools they need to make change happen at a local level.
The Triple Aim
One of the important things that we all began to realize during those initial Health for Life discussions was that when you don't have good information and you don't know how well you are doing, you can't define a pathway. You end up making these big gigantic bets on anecdotes and you can't hold a mirror up in front of the health care system and say, "Are we actually getting better?"
Think about what [Centers for Medicare & Medicaid Services Administrator] Don Berwick has been putting out there on the Triple Aim: improving the individual care experience, improving the health of the population and doing it on a cost-efficient basis. How do we know if we are doing that? How would a single hospital know? If you take care of 50,000 to 100,000 discharges a year, you don't know how well those patients are doing in the full continuum. You don't know what they do when they go back to their doctors. You don't actually know, as a hospital administrator, if they even go back to their doctors. Maybe if you run your own physician services, then you might be able to see if they went for their follow-up appointments, but very few people actually track it so you can't hold a mirror up and answer the question, "Are our patients getting the full continuum of care?"
Navigating the next couple of years, while we go through payment system changes, will be the tricky part. If I just run the hospital, I have an ED, inpatient and ancillary services. I have a fixed infrastructure that I have to support, but the reimbursement system is squeezing me down further and further. What do I do? How do I navigate to a world where I can actually get my doctors involved in tracking patients? How am I going to make an investment in the community? How am I going to improve the overall coordination of care if that coordination drops my reimbursement even further?
I know not everyone believes in capitation, but prepayment and capitation at Kaiser Permanente are really the key for how we do things. We are not stuck in the hospital mode. Bundled payments, the accountable care structure, even the value-based purchasing model are all moving us in that direction and taking a broader view of the patient. The key difference now as opposed to the 1990s when managed care was supposed to do this is we actually have the potential for good information. We could actually take a snapshot of our patients and our patient population if we are willing to work together. At Kaiser, we've been able to use real-time information across the continuum to drive system changes and get better outcomes.
To me, it is actually an exciting time and a challenge to do that. It would be nice if we could do that and not have people squeezing on the financial side. As the AHA, we have to make sure that the contraction in financial resources is at a reasonable pace to allow this change to happen. We are going to have to demonstrate that hospitals are making progress, though. The AHA and the board's task will be a lot easier if we are all moving in a direction that is getting us to a better state as opposed to just holding our own.
On the Role of Hospitals
Hospitals can play a crucial role in expanding the reach of health care delivery. It depends on how well we play with other players and, ultimately, how we take on a broader responsibility for the community. The finances don't always support that but, in a lot of ways, we are community resources. We are institutions that are devoted to maintaining the health of the community; in many ways we could be the convener. Can we navigate the changes in payment? Can we embrace them? Can we work with them? Can we mold them? I actually think we can.
The Health for Life discussions happened the last time I was on the AHA board and it was very satisfying to see that the field moved toward a point where it could embrace a more encompassing framework. The hard part is implementation. That's the challenge here at Kaiser. It was the challenge when I was in New York. We need to demonstrate that you can change the culture and you can shift incentives so that we are doing the right thing and getting higher performance. There is so much capability in the U.S. health care system that we have to tinker with it and figure out how to put it all together. It is time to break away from the extreme fragmentation.
On Managing Costs
Hospitals lose money on Medicare. They subsidize it by cost shifting, but that is getting harder and harder. So the challenge is to be profitable on Medicare rates, and I hear my colleagues talk a lot about taking costs out of the system.
People really have to look at operational efficiency. Throughput is key. We have to get length of stay down to the time that is necessary for patients to be in the hospital and then we have to find appropriate and alternative venues. It is harder for a stand-alone hospital to do that. There are things we can do with good home health or taking advantage of new technology such as in-home monitoring, for example. We have virtual ICUs, as another example. It is also time to take a look at how we deploy health care personnel. Pharmacists can do a lot more to help with medication reconciliation.
On Population Health
Everyone understands that we can't continue on this spiraling cost cycle, especially if we are not getting positive results for our population's health. We need to engage other parts of the health care industry. The key is defining parameters of collaboration that will get us to the greater good. We need to find win-win-win scenarios where we lower the disease burden in the population, we do a much better job of prevention and the care that we do render in hospitals is absolutely essential and not rework or not the result of inefficiencies or dropped handoffs or poor medication reconciliation.
We have information systems that can help us track whether we do that. We can get feedback and compare our performance versus others and, if we keep an open mind about it, we can ask and learn from other people. At Kaiser, we are looking at the variation in outcomes and performance and trying to drive for a little more uniformity. I'm not talking about taking away an individual's ability to innovate, but we need to give people the right data so they know whether their approach is actually working better or worse than another person's approach.
We have disease registries. We can virtually build registries at will. We scrub the information in an engine with algorithms that look at the evidence. We take demographic information, clinical data and pharmacy data and roll it up and say, "The evidence shows that we could pick up diseases earlier if we do these preventive things."
There has to be a systems approach to get us there. At Kaiser, we've built tools and engines that allow the front-line staff to address some of these issues. The call center staff can tell a patient, "You haven't had your mammogram screening, can I make that appointment for you?" If a patient is seeing a specialist, the doctor can see gaps in the patient's record and say, "Let's try to address these, or let's refer you to somebody who can address them." We are very proactive and that is where the health system has to go.
Can you only do it if you are completely integrated as we are? I actually think if you show doctors the information, whether they are employed or loosely affiliated with a hospital, we can address these gaps. We can work with insurers to get their points of view. Everybody needs to keep an open mind.