The Battle Over “Healthcare” in America Today

Introduction

Or is it “health care”? Or “health-care”? The battle over how to properly use the term “healthcare” has trudged on in America for many years. I have been involved in educating healthcare professionals and students here in New York City and on Long Island for over 27 years. For that entire time I have watched the phrase “healthcare” being grammatically abused by all – even by the largest book publishing companies, dictionary publishers, newspaper and magazine publishers, medical institutions, and government agencies in America.

Who Is To Blame For The Confusion?

But these very same publishers and institutions are to blame for the prolonged confusion. Some of them mandate the using of “healthcare” as one word for all grammatical situations. And some of them still insist on using “healthcare”, as well as “health care”, depending on the specific topic being discussed. To make matters much worse, some publications will even switch around the term and the way that it is used – all within the same publication. Here at our company we have consciously chosen to use “healthcare” as one word, but we certainly understand both sides of the argument. New compound words always seem awkward to use for a while. But eventually, we all accept and conform to the change. Most of us in America have already accepted the change to using “healthcare” as one word. Now it is time for the last few holdouts to accept this change and start using “healthcare” as one word.

Why We Use Healthcare

Why, then, does my medical training and publishing company embrace “healthcare” as one word? Well, “health care” may have technically been two words when the term first came about, but in all rational practicality it was one word. The distinction was a fine one – and way too subtle, obviously, to keep up. Before long, writers and editors alike started dropping that confusing extra space, transforming what had become a purely semantic nuance into no nuance at all. At my company, we have a core belief that we have an obligation to our students and readers to make everything that we teach and publish to be as easy to read and understand as possible. If this means using one word versus two, or using an unpopular or grammatically incorrect hyphen in a word, or splitting an infinitive, or using extra commas, then we will do it. Our first and foremost duty is to our students and readers, not the grammar editors or linguists.

Evolution And Improvement Of Our Language

But can we blame our language for simplifying and evolving? It’s equally possible that American society, in its infinite semantic wisdom, decided not to split hairs – or word phrases – where it is pointless to do so. This isn’t just the inescapable evolution of our language. It actually is a sensible change to make.

“Healthcare” and “Health Care” Defined

We will frequently see the word or phrase “healthcare” and “health care” but are unsure whether they are the same. Many people use each one to mean the same thing – but they were fundamentally different at first. At its most elemental definition, “health care” was a service offered by trained professionals to patients. As one word, “healthcare” meant the system in which the professionals work and where patients receive care. Healthcare as one word referred to a system to deliver health care (two words). Thus, America has a “healthcare system”. In Great Britain, it’s called the National Health Service.

We can easily see why these definitions can get confusing and become commingled. But now, most of us accept that the term “healthcare” is now a generic way of referring to any aspect of medical care – no matter what the topic being discussed. Whether it is a discussion of the diagnosis or treatment of diseases, or how that diagnosis or treatment is delivered, or how they are paid for, is now “healthcare” – one word.

Conclusion

The term “healthcare” will eventually become widely accepted as one word, whether linguists and editors like it or not. This acceptance has already occurred in British English, where “healthcare” as one word is used more frequently. Some American and Canadian publications still resist the change, still preferring both “health care” and “healthcare.” Australian English falls somewhere in-between. In any event, it’s inevitable that “healthcare” will eventually be accepted as one word.

Healthcare Industry is Growing

The healthcare industry is continuing to create jobs despite the global economic downturn. Medical training will be an utter necessity in order to provide services to the increasing geriatric population. Unemployment rates have been going up in most other sectors like retail and construction. Job cuts and recession are the biggest concern in everybody’s mind today. Healthcare schools have seen to contribute for thousands of medical industry jobs every month.

Healthcare training in pediatrics and obstetrics have high hospital demands to cater. There is a distinct upward trend in job creation with the medical and health care industry worldwide. Healthcare schools are set to thrive with the sustained increase in national healthcare spending. Medical schools play a key role in providing the skilled professionals in order to handle the aging baby boomer population. Healthcare industry has added two million jobs in the last eight years. This is considerably higher than most other private sectors. Local medical and social assistance services add to about forty thousand healthcare jobs every month. This is in significant contrast when compared with the considerable private job losses in other industries.

The healthcare industry is known to have a minimum job growth of thirty-forty thousand per month. Government policies aim to increase on the annual spending of healthcare programs. This money works to pay for the services of in-demand medical personnel. Healthcare training programs can increase employment opportunities in the hospital sector. Healthcare training programs assure job readiness with solid scopes for permanent employment. The high risk to public health crisis due to the shortage of healthcare professional is increasing in most regions around the word. Government healthcare programs can be undermined in quality from shortage of trained medical workers. A severe crunch in medical manpower arises from the increasing demand of medical services.

Healthcare schools work to reduce the growing disparity in demand for medical services and the available personnel. Healthcare program graduates will be in high demand over the next several decades. The fastest growing employment category is with geriatrics and nursing. Career growth potential with education from the medical schools is said to double. Healthcare programs that work to train nurses are struggling to meet the increasing demand for qualified professionals. There is a chronic international shortage of four million trained healthcare professionals in the current year. Medical healthcare programs that offer graduate degree in healthcare have the highest job potential for the next five years. Healthcare providers continue to hire, as there is no risk to shrinkage in their end market. Government medical programs for the public are immune to the budget constraint measures. The costs of healthcare services continue to grow higher than the average national income. Major job-reports and labor statistics identify healthcare as a recession proof sector.

A decrease in private medical spending during recession is offset by public Medicaid expenditures. The projected annual spending on healthcare is said to increase by one fifth of the country’s GDP in the future. A career in healthcare can guarantee growth and security even during the difficult times.

Why Healthcare Marketing Is Different

Power Structure of Healthcare Organizations

The most prevalent difference of healthcare organizations from others is that in healthcare, head administrators and such DO not make most of the decisions that affect patients (customers), but physicians do. There is a unique dynamic in healthcare organizations in the relationship between its business and administrative leaders and the providers of medical services.

Payment of Services

Unlike most businesses in other industries, healthcare organizations do not get paid until after services have been rendered because, as also different in other industries, the consumer receiving services is NOT who is fully responsible for paying for them.

Healthcare organizations receive most of their reimbursements through third party payers (insurance companies, Medicare), which can take up to a month or longer to process.

The End User

Unlike many industries, like retail for example where goods are marketed directly to potential customers, most marketing efforts of healthcare organizations do NOT target end users (patients, customers).

Healthcare organizations, especially those that provide specialty care, rely on the referrals of other physicians (primary care physicians) to build their patient base. Thus, specialty practices will focus their marketing efforts towards building relationships with other providers.

Seller Discretion

In most industries, potential customers that cannot afford a service or product can be denied service.

However, in healthcare, organizations (especially non-profit organizations) have obligations to accept patients regardless of their ability to pay. In emergency rooms, patients with emergency care MUST be seen at least until they are stabilized. Physician practices may require payment to be made before the visit, however, the practice must consider ethical and liability concerns before they decide to turn away a symptomatic patient based on their lack of means to pay.

Profitable Services

In most industries, business will generally not provide unprofitable services.

Healthcare organizations, like any other business, must turn a profit in order to keep its doors open. However, unlike other industries, healthcare organizations often provide services that are not profitable. As in situations explained above regarding emergency rooms, healthcare organizations have ethical and legal considerations that do not affect businesses within other industries.

Healthcare services are provided within a course of patients care. If a service is necessary to progress a patient’s course of care, it should still be provided even if it is not profitable.
Example:

A patient’s chemotherapy regimen may include a drug that is not profitable to give, but is necessary to complete the regimen.

Supply and Demand

Typical laws of supply and demand generally do not apply within healthcare, as an increase in supply does not necessarily lead to a decrease in prices, and an increase in demand does not necessarily lead to an increase in prices.

Although healthcare organizations set the prices for the services they provide, their reimbursement is usually dictated by their managed care contracts, and an organization will be reimbursed a set fee regardless of what the price they charged. Prices for services mostly apply to self pay patients.

Demand for healthcare services is usually not dictated by the consumer, as they do not choose what services would be necessary to continue their care. Such decisions are made by physicians.

Although demand in any industry is unpredictable, it is considerably more so in healthcare as consumers do not choose when they need service and the need is realized unexpectedly.

Products and Services

Healthcare mostly markets services rather than tangible goods. Therefore, in most cases, marketers are not marketing a specific product but a service and who is providing the service and how it is performed to attract consumers. A consumer of a tangible product will base their level of satisfaction on the product on its use and performance. The consumer of a service will base their opinions on factors such as customer services, wait times, condition of the facility, the demeanor of those providing the service, and the processes used to provide the service amongst many other factors.

Healthcare products and services can be so complex that they are rarely understood by the end user. Unlike the retail industry for example, where a consumer identifies a need for a product and will fulfill that need by purchasing the product, healthcare consumers rarely choose the services they will receive. Consumers of healthcare services seek the services of physician who will then choose what further services are necessary to treat the their condition.

Even in cases where services are marketed directly to a patient, for example robotic surgery for a particular condition, the service can be so complex that it must be marketed in a way that are understandable to patients.

Undesirable Consumers

Most businesses would welcome any consumer to purchase their products or services as the CONSUMER would be responsible for paying for such products and services when they receive them. Because consumers of healthcare services are usually not responsible for the payment of services at the time they are provided, as this responsibility is of third party payers, healthcare organizations must attract consumers that are not potential financial liabilities.

Although physicians are obligated to treat patients regardless of if they have insurance or means to pay, marketers must attract consumers with insurance policies whose reimbursement rates will cover the costs of the services provided.

Bringing Lean Healthcare to Life

Starting Blocks

Without a doubt, Lean is set to make a big impact on the Healthcare sector over the next few years and many Healthcare organisations in both the public and private sector are already exploring how they could apply it to their patient pathways and administrative processes.

Whilst many of the tools of Lean are familiar to the people in the Healthcare sector, particularly aspects of Process Analysis, the real difference that Lean will bring is a change in the way that improvements activities are implemented rather than the use of the tools themselves.

Many people in the Healthcare sector are looking to people with Lean skills gained in manufacturing to help guide them through the maze of implementing Lean, including helping the organisation to prepare for Lean as well as undertake the specific improvement activities, including Value Stream Events, Rapid Improvement Events etc. Running alongside this is the need to develop the internal capacity of organisations to lead improvements themselves, which is achieved by developing internal Lean facilitators (or Change Agents).

However, as we already know, not every problem in Healthcare can be related to a problem encountered in Manufacturing and there are some significant differences in approach required to make for a successful improvement programme for people more familiar with leading Lean improvements in Manufacturing.

In this article we review some of the key differences that we have found in pioneering Lean transformation in Healthcare and share the structure to Lean activities that we have been developing to ensure that the organisations make sustained improvements rather than isolated Lean ‘ram raids’.

Interestingly, our work to date is also providing some useful learning that can be applied in reverse – from Healthcare back into Manufacturing!

The Same, But Different

As we have already said, Lean will make a big difference to Healthcare and will help them achieve their operational and financial targets but it needs to be applied sensitively within organisations that have been ‘pummelled’ by initiatives and legislation and have a not unreasonable cynicism towards ‘this new initiative called Lean’.

Like in many manufacturing businesses first embarking on an improvement journey, Healthcare employees are concerned about Lean being a vehicle to cut jobs. This feeling has not been helped by the recent NHS guide issued about Lean Healthcare which has chosen to use a Chainsaw as their main logo and was referred to by a Service Improvement Lead within an SHA (Strategic Health Authority) as the ‘Slash & Burn’ guide to Healthcare.

Issues such as this, along with the use of manufacturing focused terminology, photos and case studies when working with employees in Healthcare, has the effect of building up internal resistance and leads to comments such as “My patients are not cars” made by a Renal Consultant we encountered recently.

Additional differences can be seen in the attitude towards risk in Healthcare. In Manufacturing, if you make a mistake with Lean you may increase the risk of accidents but it is more likely it will just reduce productivity or profits. In Healthcare, similar mistakes can impact on Patient Safety (including increasing Morbidity or even Mortality) and can attract significant media attention.

Making this scenario even more complex is the fact that the ‘care pathways’ that patients experience often interact and overlap in a way that Manufacturing value streams do not, with patients switching between pathways and specialities dependent on their specific needs and treatment plans.

Management of these processes and pathways is complicated by the need to balance clinical concerns (such as patient safety and medical best practice) with ‘business’ concerns (availability of resources and finance), and the often uneasy balance that has to be struck between senior clinicians and organisational managers on these issues.

Whilst this sort of complexity is not alien to manufacturing, where there is a constant need to balance cashflow against sales (for example), the fact that this balancing and the resulting management of risk in Healthcare is so prevalent leads to a very different style of management – being more consultative and inclusive than Manufacturing, which slows decision making and involves a lot more analysis than many Manufacturing decisions, and the need to prove things first to sceptical clinicians.

This constant need for balance between clinical and operational concerns leads to one of the biggest differences we encounter, namely the difficulty in engaging the right people for the right amount time to make the improvements sustainable. This is not a new problem in Healthcare with many improvement initiatives having fallen foul of changing priorities, the allocation of insufficient people to an improvement process or simply having failed to move from discussion into action quickly enough.

One final difference between Manufacturing and Healthcare that we thought useful to highlight is simply the differences between what ‘customers’ think of as Value Adding in the two sectors. Giving comfort and advice to a patient is highly valued (for example, a nurse accompanying a patient being taken to theatre) but does not translate easily into a manufacturing equivalent activity.

A Holistic Approach
To counter these issues, introducing Lean into Healthcare requires a holistic approach that takes into account the following points:

1. Understanding Customer Value

Whilst the patient is the obvious (and most important) customer in a process, they may not be the only customer in a Healthcare environment; with others including (say) a Primary Care Trust that has commissioned a Hospital to undertake some activity on a patient and which will be invoiced for the activity.

However, in exploring what customer think of as value adding we do find some customers (patients) in Healthcare have become conditioned by their experiences to date. In one example we were speaking to a patient who attended clinics weekly as part of their treatment plan and was required to wait at every appointment for up to two hours. When we discussed what they valued and whether a reduced waiting time would be beneficial, they said they had come to expect the wait and would place more value on access to free coffee and better magazines to read!

2. Scoping Effectively

Identifying a compelling need for the improvement process is absolutely essential. The need to improve productivity or finances are often driving improvement initiatives in Healthcare but a compelling need based on saving money will rarely engage people from across the pathway.

Often a successful compelling need will focus on improving patient outcomes and achieving the statutory targets within public Healthcare (such as achieving an 18 Week maximum lead-time from referral by a GP to the start of treatment) as well as the need to achieve best practice rates for activity. Because of the importance of this step in the process, we have shown what we believe are the key elements required to successfully scope an improvement project in the text box opposite. It is worth stating that to be truly successful, the scoping of Lean improvements relies on having representation from across the pathway – even if, as is so often the case, that means including people who have never considered themselves as co-workers before, such as the GP and the Hospital Porter we had sitting next to each other at a recent Scoping session.

3. Effective Sponsorship

Leading a Lean project that spans such broad patient pathways requires a high degree of influencing skills. Even seeking to improve a simple administrative process like a Patient Discharge for example, could require the Project Sponsor to liaise, cajole and drive change across several stakeholder groups including GPs, consultants (the real custodians of the NHS), ward staff, medical secretaries, pharmacy staff, IT, social services and porters!

The Sponsor’s belief in Lean will be tested daily by such a large group of interested parties and so their capacity to maintain enthusiasm and motivate the Change Agents is vital. The secret weapon at their disposal, once the Scoping session has been completed is that an agreed Compelling Need will create “clarity of purpose”. Ultimately, if they engage enough people with the same message enough times, the followers will start to assemble.

4. Building Awareness & Capacity

Given the concerns of many in Healthcare that Lean is going to be used to shed jobs, it is essential that there is thought given to the communication of the ‘Compelling Need’ – what Lean is, what it is not and what will happen. Running alongside the raising of awareness will be the need to focus on developing the capacity of individuals within the organisation to enable them to lead Lean improvements.

In addition to initial awareness activities, there is also a need to build on-going communication activities to report on progress, involve others in the design of new processes and ensure that the organisation embeds the improvements achieved before (or alongside) moving onto the next challenge.

Our experience of this shows that at the start of the process a lot of people think of Lean as being just about ‘Process Mapping’ and there is a certain cynicism about it in many areas. This is quickly overcome but can be quite demoralising when first encountered and this confusion about Lean underpins the need to develop broad awareness within the organisation of what Lean truly can deliver.

In terms of capacity, many Healthcare bodies are keen to build internal capability to develop themselves as Lean organisations. Performance Improvement Teams are popping up all over the place and we have found that a large part of our work has been focused on helping these teams of change agents develop the facilitation skills and leadership attributes that will enable them to not only deliver change but make it sustainable.

5. End 2 End Understanding

We mentioned earlier that one of the ways that Lean in Healthcare is different to Lean in Manufacturing is that the pathways (value streams) interact in a different way. Another problem is often encountered through isolated events in one area having an unexpected (and often negative) impact either upstream or downstream in the pathway. Given the risk associated with making changes in different parts of Healthcare, we believe it is essential to develop an understanding of how the pathway operates from End 2 End and to review its critical constraints, current operating performance and the impact that likely changes might have elsewhere before seeking to create a suitable ‘Future State’ and implementation plan.

6. Embedding the Change

Much like Manufacturing, a large percentage of Lean projects in Healthcare are going to fail to deliver the results that organisations hoped for and many of these problems are related to the challenge of embedding the changes. So, having gathered support for an improvement programme and achieved the changes (through Focused Improvement Teams, Rapid Improvement Events etc), it is critical to also conduct the activities that will assist the embedding of the changes including:

 Publicity and communication of how the new systems/processes work
 Celebration of the improvements achieved
 Reviews of achievements (Progress Gates) which look back at what has already been done
 Auditing to ensure the changes don’t slip back to ‘the old way’
 Further events and activities (as one success often breeds further successes)
 On-going Change Agent Development
 On-going, visible Sponsorship.

No Magic Bullet
When we opened this short article, we mentioned that Lean is set to have a big impact on Healthcare as it can address the needs for improved effectiveness as well as reduced lead-times and costs, but that its application is different to the way that improvement activities are led in Manufacturing and has different risks and threats to success than in other sectors.

We do not claim to have a monopoly on good ideas about how to address these points and have written this article from the basis of real experience of delivering improvements to a variety of Healthcare organisations. We would welcome feedback on your experiences.

As a closing thought to Lean practitioners everywhere who are looking to be (or are already) involved in Healthcare – whatever the operational benefits that are possible, no-one wants to achieve these at the expense of patient safety – as it is only by addressing both operational and clinical needs that Lean Healthcare will truly come to life.