Steven Goldstein, president and CEO of Rochester, N.Y.-based Strong Memorial Hospital, part of University of Rochester Medical Center, is an experienced and refined healthcare leader and advocate.
With a nuanced understanding of healthcare's many challenges, Mr. Goldstein sees new opportunities to improve care delivery and the promise of new medical developments. Mr. Goldstein took the time to describe some of these challenges, along with his thoughts on the importance of scale in today's healthcare environment, the biggest changes he is observing and what excites him most.
Question: What are the most interesting issues that you see in healthcare today?
Steven Goldstein: From my point of view, the consolidation of providers into more cohesive networks is one of the most interesting issues
in healthcare today. Certainly, this brings enormous challenges in terms of blending disparate groups, but there is also an unprecedented opportunity to maximize our healthcare assets by bringing together institutions and providers that have not collaborated in the past.
Developing models of care that are high-quality and cost-effective, and that provide care to patients in the least expensive setting, is one of the great management challenges that the healthcare industry faces. In addition, how to sustain care models in rural areas, which are neither population- nor resource-rich, is an enormous challenge as well. Safety-net institutions represent a separate category of challenges. Capital, sufficient operating revenue and philanthropy are frequently lacking, thereby making the transformation of care to population health and the ability to assume risk for populations with high needs incredibly difficult, if not impossible.
How we will develop a healthcare system that is responsive and affordable to all across the continuum — in both urban and rural settings — is a tremendous challenge requiring more efficient management and financial systems that must be developed and implemented.
Q: How large does a system need to be today, and why?
SG: In the new delivery and risk-payment models, scale matters. Networks must be large enough to spread risk and take advantage of efficiencies of scale. The exact size depends on the mission that one is trying to support. Academic medical centers, for instance, must be able to draw upon a large population to support specialized services for high-complexity patients. For those institutions with quaternary and tertiary programs, a service area of three-to-five million people may be necessary to support highly specialized patient care programs. For insurance contracts with risk arrangements, covered lives in the range of 300,000 to 500,000 would seem to be reasonable in distributing risk effectively.
What is interesting is that within the population health framework, the definition of system is evolving. No longer does the number of participating hospitals define a system. Systems are ecosystems comprised of diverse practitioners, multiple access points like urgent care centers and free-standing emergency departments, institutions that span the continuum of care, insurance entities, educational institutions, management service organizations and more, all powered by information technology. The focus of a system is now on the provision of cost-effective, high-quality care that appropriately uses the most expensive components of healthcare and manages information and the business components within the system effectively.
Q: What is the biggest change happening in patient care?
SG: I posed this question to our medical director, who is a practicing internist. He noted that the sequencing and exploration of the human genome has opened the door to "tailored" therapy that heretofore has not been possible. "Big data" analysis of the genome has not only enabled breakthrough, targeted therapy, but it also allows us to clearly assess just how well existing treatments work for individuals based on their distinct genomic characteristics. Examples of this are in breast cancer, where high-risk individuals can be identified using genomic markers and treatment plans, which can be personalized based on the specific genetic characteristics of the patient.
By focusing on value rather than volume, we have the potential to positively affect both the cost and quality of care delivered and raise the standard of health for specific groups as well as the population as a whole. This is made possible by the computerization of the medical record, which gives us the ability to share information across the spectrum of providers and settings, and the analytics to prove just how well we are preventing and intercepting illness and driving down costs.
From the patient's perspective, the efforts to improve access and the rise in consumerism have been dramatic. More choices exist for patients to seek accessible care, whether through walk-in clinics, free-standing emergency departments, urgent care centers or ambulatory surgery centers, all located in easily accessible locations. The quest for patient satisfaction has never been greater in the industry and is truly becoming the norm rather than the exception.
Q: What excited you about the future of healthcare?
SG: America's healthcare system is unsustainably high-cost, with variable quality and access. New delivery systems must be developed that seek to solve these problems in the decades ahead. As we look at each of these components, we understand that sweeping changes must occur to provide affordable, high-quality healthcare to all citizens regardless of where they reside. Devising the right approach is, of course, the challenge at hand. The strategic alignment of institutions and individual practitioners are important components of the healthcare system, which will affect how and if they provide services in the future.
While much has been written about health reform, much is still unknown. The efficacy of population health approaches are still a matter of conjecture and experimentation. The movement from volume to value is still, for many, a transformation goal. Whether institutions can align themselves in ways that truly bend the cost curve, provide high-quality care and do so in a way that is financially sustainable is truly a challenge of our time. What is exciting about being a part of the healthcare delivery system today is that the stakes have never been higher to find real solutions that address the fundamental issues driving healthcare reform. Whether it is new organizational forms or fundamental incentive adjustments to the system, the challenge — and the opportunity — for management at all levels has never been greater.