Amid pressure to control healthcare spending, New Jersey hospitals are preparing for a future when keeping people healthy is as vital as taking care of them when they are ill or injured.
To do so, hospitals are providing more outpatient services focused on disease screening and prevention, and opening fitness centers where members are coached toward a healthier lifestyle of regular exercise and good nutrition.
Right now “wellness initiatives are an expense that we are incurring that no one pays for,” said Barry Ostrowsky, chief executive of Barnabas Health. “But we view this as part of our mission, so to the extent that we are earning a margin on sick care, we are applying some of that margin to support these wellness programs.”
Health and fitness centers are operated by the hospitals in the New Brunswick-based Robert Wood Johnson healthcare system, Virtua in South Jersey, CentraState in Freehold, and University Medical Center of Princeton, among others.
The West Orange-based Barnabas Health system has a major ambulatory care facility in Livingston with a health and wellness center part of a diverse array of outpatient services, from mammograms to EKGs to screening teenage athletes for heart ailments that can cause sudden cardiac death on the playing field.
The 2010 Affordable Care Act seeks to reward better health and disease prevention in a number of ways, including fostering the creation of Medicare “affordable care organizations,” where hospitals and doctors get to keep a share of the money that Medicare saves if healthcare spending declines and patient outcomes improve.
The ACA will also reduce imbursements in 2013 to hospitals that too often readmit patients within a month of their discharge, thus motivating hospitals to find ways to keep patients healthy after they go home.
“The big push behind health reform is that we think people use the hospital too much, and we would prefer they stay healthy and stay out of the hospital,” said Derek DeLia, associate research professor at the Rutgers Center for State Health Policy. “So for hospitals to be relevant, they have an incentive to really be part of that, rather than just a bystander.”
Kirk Tice is chief executive of Robert Wood Johnson University Hospital Rahway, which operates two fitness and wellness centers in Scotch Plains and Carteret. Robert Wood Johnson University Hospital in New Brunswick has a fitness center in Parlin and will open a new one later this year in New Brunswick. The system’s Hamilton hospital has a fitness center in Mercerville.
“These are medically-based fitness centers,” Tice said. The average age of members is just over 50 -- “people who wake up one day and say ‘I had better start taking care of myself.’” But anyone who joins, regardless of age, is screened for basic health indicators like blood pressure, heart rate and body fat. “My son is 16 and he’s played sports all his life. He signed up as a member, and they will not let him exercise until he has a visit with the nurse,” Tice said.
The two fitness centers’ combined enrollment of 10,000 are mostly healthy adults looking for a place to exercise. But as medical fitness centers, they provide physician-prescribed physical therapy and rehabilitation services to patients recovering from orthopedic surgery or cardiac procedures.
“Our goal is really to give them the tools and the confidence [to exercise] following the diagnosis of heart disease,” said Tice, who is 58 and a skier. “People who make reasonable efforts to watch their diet, who are trying their best to get some exercise and avoid unhealthy habits -- those are the people who tend to be pretty healthy and active.”
Virtua has two fitness centers, in Voorhees and Washington Township and will open a third in Moorestown by the end of the year. Richard Miller, chief executive of Virtua, said anyone can join, but they are especially geared to “people with issues like arthritis and heart disease, who typically didn’t want to go to a fitness center because they were intimidated by it.”
When Virtua opened its first center in Voorhees in 2000 “my thought was that healthcare organizations are going to have to get into the business of keeping the population healthy, versus just taking care of sick people.” The centers are especially popular with adults in their 40s and baby boomers “who take wellness and fitness very seriously, who are taking better care of themselves so that they can still do things at an older age that they can do today.”
Ostrowsky, chief executive of Barnabas Health, is convinced that hospitals belong in the wellness business. The system’s ambulatory care center in Livingston, in addition to providing same-day surgery and treatment for multiple sclerosis and celiac disease, is a major center for breast cancer and osteoporosis screening. It also provides health and wellness programs to individuals coping with ailments like arthritis, diabetes and heart disease. What all the services have in common is that they treat thousands of patients who need care but don’t require a hospital bed.
Ostrowsky said one of his frustrations is that while private insurers and the government will pay for medical procedures and for preventive screenings, they don’t reimburse for community wellness education. The system's Newark Beth Israel Medical Center, for example, is deeply involved in efforts to reverse childhood obesity, including trying to bring a new supermarket to the hospital neighborhood to improve access to fresh, nutritious food.
Barnabas partners with other stakeholders “to help us spread the word, to help us mount the campaign where we can hope to persuade people that there is a healthier lifestyle out there, one that is good for everyone,” Ostrowsky said.
Medicare ACOs will give healthcare providers a share of the money saved through improved population health, and Ostrowsky wants “to take that additional revenue, and invest it in wellness. I love the idea of giving more efficient sickness care, but I want to be the beneficiary of that efficiency so that we can keep improving sickness care, and allocate some of that profit to wellness.”
Miller said there is no question that healthcare providers have to figure out how to reduce the nation’s medical bills. He expects the economics of healthcare to evolve away from the current fee-for-service system, which rewards healthcare providers for every service and procedure they do. Instead, he believes providers will eventually “receive bundled payments for the entire care. From the time [patients] go into the physician's office, to the hospital, to post acute care, we are going to get one payment for all these episodes, as opposed to getting individual payments for each episode.”
This will give healthcare providers a financial incentive to keep people healthy. “In order to manage this, we’re going to have to keep trying to keep the baby boomer population out of the hospital system, try to keep them well and prevent disease,” Miller said. The Virtua fitness centers are a critical part of the equation, since they help individuals with chronic diseases like diabetes stay on track after they receive acute care for their ailments.
“Our fitness floor has an area specifically for cardiac patients,” Miller said. “And with the way stress in involved today in everybody’s world, we’re seeing patients in their 40s, right through age 70 and 80. So we have patients who present early with cardiac disease who we really pay special attention.” Individuals get a health assessment to alert them to the risk factors they need to manage, and the center will help them find a primary care physician if they don’t already have one.
As the hospital manages chronic disease outside its walls, the hospital will specialize in providing intensive care for the really sick, Miller said. To hit the national goal of holding the line on healthcare spending, total spending for prevention, outpatient services and wellness will need to be less than if we continue along the path of waiting until people get sick and providing them with expensive sick care.
“The revenue won’t be as large, but you will have the diversification of products on the outpatient side to support the future,” Miller said. “Anyone who is banking on needing more hospital beds in the future is making a mistake. I don’t think we will need more beds in the future. There will be more outpatient service needs and more primary care in the future.”
DeLia of Rutgers said if healthcare providers “change their service mix a little bit, so that they actually do well when patients do well with their health, then that makes good sense for a lot of hospitals.” He said most hospitals can provide more ambulatory care, since the already do this in their emergency rooms.
Hospitals are positioned to take the lead in wellness, Ostrowsky said. “When your specialty is treating sickness, among the things you know is how people get sick, so we are a credible source for helping people. I have always viewed us as being in the social service business, and our number one product line is sickness care. I think it’s time for us to pay attention to things that aren’t sickness care.”
But not every hospital will take the road to fitness and wellness, DeLia said. “Some might not be good at it, and they will want to stick to their core competency of trauma care, delivering babies and surgery.” And he said there would remain a role for the traditional inpatient hospital because “people are definitely going to keep getting sick. Especially if you keep them well, they are going to live longer, and if people live longer you will have 80, 85 and 90 year olds to take care of. And they are going to need to check into the hospital from time to time.”