Healthcare faces a long list of daunting challenges, from spiraling costs to drug-resistant infections to millions of uninsured patients. Who is showing the courage, the creativity, the perseverance to meet those challenges? Who is truly making a difference in today's complex healthcare world? In our annual HealthLeaders 20, we offer profiles of individuals who are doing just that. Some are longtime fixtures in the industry; others would clearly be considered "outsiders." Some of them are revered figures; others would not win many popularity contests. But all of them are playing a crucial role in finding ways both large and small to make the industry better.
Susan Hunt, voice for the underserved
With its warm beaches and blue waters, it's hard to believe Hawaii would have a tough time recruiting primary care physicians. But low reimbursement rates, high real estate costs, and distance from the mainland make establishing a practice difficult, particularly in rural areas.
That's why the Hamakua Health Center's expansion into Kapa'au, HI, was such a landmark event for the Big Island. At the end of 2006, there was just one physician left in Kapa'au, and residents were left fighting for access to care.
"The community approached us and asked us if we would take over the practice and open a satellite in that community," says Susan Hunt, MHA, executive director of the Hamakua Health Center, whose main clinic is located in nearby Honokaa. Hamakua's executives had expansion in the organization's strategic plan, but with one physician remaining in the region, that plan accelerated—and quickly.
"This was an area of the island that wasn't providing care for the underinsured or uninsured population," Hunt says. "Its physician was having such a hard time that we thought this was an opportunity to carry our mission to that community."
But bringing accessible primary care to Kapa'au is just one of the many things that Hamakua Health Center has done under Hunt's leadership. "It's not just providing medical care," she says. "It's a whole array of social service programs: oral health services, mental health . . . You have to look at the whole package." In 2009, Hamakua Health Center will begin running a mobile dental health van between its two clinics, expanding the scope of care offered to residents of Kapa'au and Honokaa.
And Hunt's belief that healthcare should be accessible to all goes beyond her work at Hamakua. She's currently serving on a task force set up by County of Hawaii Mayor Harry Kim that brings healthcare and business leaders to the table to identify solutions to the limited healthcare options available to residents of Hawaii County.
Marc T. Zubrow, telemedicine advocate
Anybody paying attention to the nation's physician shortage, particularly in rural areas, is well aware of telemedicine's role in filling the void. And anybody who is paying attention to telemedicine has heard of Marc T. Zubrow, MD.
Zubrow is leading an effort to bring top-tier critical care to the countryside. The director of Critical Care Medicine at Wilmington, DE-based Christiana Care Health System, Zubrow is also the medical director of the Maryland eCare project, which in the coming years will connect at least six rural hospitals in the Old Line State to Christiana's eICU program. For Zubrow, the basic equation is simple.
"From Christiana's care perspective, we wanted to improve regional outreach and further support for our eICU program," he says. "From the Maryland hospitals' perspective, they are addressing a clear shortage of critical care physicians in these smaller, rural hospitals." Zubrow says eICU lets smaller hospitals maximize their staffing efficiencies by providing critical care during overnight and off hours, thus relieving on-site physicians from hours of extra duty. "Whereas, if you need a 24-hour-a-day setup to provide ICU patient care, you need at least five physicians, and a 200-bed hospital on the Eastern Shore is not going to be able to find that many physicians," Zubrow says.
Telemedicine also has indirect benefits. "It allows the hospitals to care for sicker patients locally, and that is a huge satisfier for patients and their families," Zubrow says. "From a financial standpoint, the rural hospitals are getting the reimbursements for care, rather than having to pay a tertiary hospital they refer to for that same care."
Harold P. Freeman, patient navigation pioneer
The list of accomplishments for Harold P. Freeman, MD, is a long one: He is the president and founder of the Ralph Lauren Center for Cancer Care and Prevention in New York City, and he is senior advisor to the director of the National Cancer Institute. He's a professor of clinical surgery at Columbia University College of Physicians and Surgeons. Served as American Cancer Society president from 1988 to 1989. Chairman of the United States President's Cancer Panel for four three-year terms under the first President Bush and President Clinton. Director of surgery at Harlem (NY) Hospital from 1974 to 1999. Winner of multiple awards.
But it's Freeman's "patient navigation" concept that may be the accomplishment that provides the most help to people who need it the most. Freeman pioneered the patient navigation program in 1990 in Harlem after studying racial and economic disparities in cancer treatment access. The program uses patient navigators to guide medically underserved patients through the fragmented health system, from the initial finding of potential cancer to formal diagnosis to treatment, and helps remove barriers to diagnosis and proper care, whether those barriers are inadequate finances, poor language skills, or sheer fear.
Freeman's patient navigation model spawned The Harold P. Freeman Patient Navigation Institute, launched in January to provide patient navigation training and certification to representatives of organizations looking to develop or expand patient navigation programs. So far, the organization has trained 105 people from as far away as Hungary.
The patient navigation model is unique because it integrates assistance for every stage of the healthcare process, Freeman says. "People need to have tests done, but if they have an abnormality, it needs to be resolved in a timely way. It sounds simple, but it's really not. We are overseeing every step of this patient's movement through the medical system."
Although the concept of patient navigation has grown well beyond its origins in Harlem, Freeman says the individual stories of people triumphing over disease still offer the most lasting affirmation that his work is making a difference. He recalls one uninsured 54-year-old man who was convinced by a navigator to have a colonoscopy. "The colonoscopy showed a 10-centimeter tumor in his colon. Thirty days later, he had it removed—it was cancer of the noninvasive type, so he's cured," Freeman says. "I still see him on the street sometimes and talk to him. You see things like that, and you really know you're saving lives."
Nancy Goler, collaborator in California
The key to Kaiser Permanente Northern California's Early Start Program is collaboration—and that means more than just the health plan and medical team working together. The Early Start Program brings together OB/GYN clinicians with licensed substance abuse experts in a comprehensive obstetric clinic-based prenatal substance abuse treatment program that universally screens all expectant mothers for drug, alcohol, and tobacco use and helps them avoid those substances.
As Early Start's regional medical director, Nancy C. Goler, MD, plays a major role in that collaborative spirit. Goler leads the medical and research teams that are improving outcomes and reducing costs by preventing risky pregnancies and long-term—even lifelong—health issues. Goler works closely with regional director Cosette Taillac to set the program's vision and metrics. "This really shows how having the medical group and the health plan working together is able to propel a program," says Goler. The health system employs social workers in each of its 42 outpatient obstetric clinics. They work hand-in-hand with medical staff to reach out and help the women tackle potential substance problems. The Early Start Program screens nearly 40,000 women annually.
Those who are identified as having a risk of using alcohol, tobacco, or other drug use during pregnancy are referred to an on-site specialist, who is a licensed clinical social worker or marriage and family therapist. The specialist conducts a psychosocial assessment with the patient. The counselors use motivational therapy, cognitive/behavioral therapy, and psychodynamic therapy as techniques to reach out to at-risk patients.
Goler points to a study earlier this year as a compelling argument for the program; the research showed that the program is improving maternal and newborn health by getting the women treated.
Ron J. Anderson, public hospital leader
Ron J. Anderson, MD, was in the battle of his life, and he couldn't even fight back. That's because as president and CEO of Dallas' only public hospital, Parkland Health & Hospital System, Anderson wasn't allowed to directly lobby the public to approve a tax increase to build a new hospital to replace the 675-staffed-bed, 1954-era facility. It turns out he never needed to worry—plenty of prominent Dallas residents did that job for him as the measure passed by a landslide.
Anderson has long been an advocate for the poor that constitute the majority of his hospital's patients, and Parkland walks the talk while remaining profitable—at least on operations—at a time when many public hospitals are closing or asking for bailouts because they can't make the numbers work.
"I'd love to tell you we're just better managers than the people running other public hospitals, but our local county has been very generous to us," he says. "They've given us more than $400 million in taxes this year, but that's still $150 million short of what we spent on charity care, so we have to fill the gap."
Anderson and his team have unquestionably been good stewards of the county's money. Operating revenues at Parkland increased 14.2% from 2004 to 2005 and 18.7% from 2005 to 2006, while operating expenses increased 8.1% from 2004 to 2005 and only 5.1% from 2005 to 2006—the latest periods for which numbers are available. Mean while, the hospital provided $512 million in uncompensated care in the past fiscal year and logs about 140,000 ED visits each year.
Anderson is the first to admit he's no kid anymore—he was named CEO in 1982, at age 35—but his legacy is strong at a hospital that shouldn't have been able to retain him this long in an era when the average hospital CEO's term is about three and a half years. "I've had several faith-based institutions with great missions offer me twice what I make," he says, "but I've stayed here because I can still see the promise for what we can do."