Joel Kauhl, the first patient to walk through the doors of Baylor Scott & White’s new downtown Austin clinic, needed nearby care above perhaps all else.
Kauhl, 70, lives downtown in a city-run apartment complex for elderly people and, after working for years as a concierge at nearby buildings, had long since given up the hassle of a car. A January fainting spell landed him at University Medical Center Brackenridge, where he was diagnosed with prostate cancer. The care he initially deemed excellent was followed by days of frustrations as he stayed in a sprawling institution where one department seemed to not be communicating with another.
A month later, when he found that a new, human-scale clinic had opened up within walking distance, it was not so much the clinic’s tech-centric setup that appealed to him; it was simply having a convenient option in a place that was designed to remove many of the annoying aspects of the patient experience.
“It’s a real boon to have something like that nearby,” Kauhl said. “It’s a gift.”
The new clinic is a small piece of one of the most important emerging changes to Central Texas. Thanks to a combination of free-market forces and taxpayer dollars, big-city health care — a long-sought, elusive goal — might finally be arriving in the nation’s fastest-growing big city, possibly in ways that will be noticeable to the everyday patient.
Visually, the most notable change is the opening this month of Dell Seton Medical Center at the University of Texas, the new downtown hospital that will replace UMC Brackenridge.
Some health care officials have far grander ambitions. Many of the major players, from officials overseeing the new medical school to Baylor Scott & White executives eager for a piece of the Austin market, say they want to change health care in fundamental ways.
Experts say health care evolved into a tangled, bewildering system for logical reasons, and making changes means taking risks that might cut into health care providers’ budgets. Too many missteps could put their financial stability in jeopardy.
Still, many of the major players say they need to change much of what a patient experiences: the way hospitals and clinics are organized; the way doctors decide treatment; the way health care providers measure how effective a treatment is; and, above all, the bureaucratic challenges patients face.
“When someone has the flu, they call for an appointment and drive down, wait 40 minutes — that’s a typical wait time — then have a 12-minute visit that ends with a prescription for some medicine. Why can’t they do that over the phone?” said Clay Johnston, dean of the UT Dell Medical School. “That’s a simple example of how nonfunctional and nonhuman-centric the system is.”
Improving those aspects of health care can ultimately keep people healthier, experts say.
In the basement of a Brackenridge annex, one of the early examples of this ambition is being tested, writ small.
A new approach?
Juventina Martinez came to the UT medical school’s new orthopedic clinic for help with an aching back and sore hips.
The clinic is housed in a space that looks suspiciously like a dungeon. Martinez, 63, speaks no English and has no health insurance. She is the kind of patient who is the focus of the orthopedic clinic, as well as of the medical center itself.
Voters approved a property tax increase in 2012 on the promise that it would cement a partnership between government agencies and the Austin-based Seton Healthcare System, ultimately yielding a new medical school, teaching hospital, affiliated facilities, better care for poor residents and, at a basic level, a new way of administering medicine.
In a small exam room, Devin Williams, a nurse practitioner with a chiropractic background, ran Martinez through a series of “raise this” and “how does it feel if I ask you to extend your leg?”-style questions.
“She has arthritis in her knees,” Williams told Martinez’s 24-year-old granddaughter, Patricia, who had accompanied her. “But we don’t want to do something so drastic as surgery without taking other steps first.”
Williams recommended a series of home exercises to help with the pain, rather than, say, seeing a physical therapist whose service might not be necessary. Soon the unit’s head, orthopedic surgeon Karl Koenig, joined them and, after a few questions of his own, confirmed the decision.
The difference between Koenig’s unit and the care such patients often receive, he says, is that his eight-person team will collectively monitor Martinez’s care. If she does need surgery, it will only come after other options have been explored. And Martinez won’t be bouncing between groups of health care professionals who have little, if anything, to do with each other most of the time.
Unlike many doctors, Koenig is also not paid on how often a patient makes a clinic visit. Koenig said his team’s approach, as obvious as it can seem, is uncommon in the health care field.
When he was a surgeon at the Dartmouth-Hitchcock Medical Center, he would often meet with patients complaining of joint problems and find himself with two options: operate himself, or send them to find some less invasive solution themselves. In the latter case, the patient would be left largely on their own to deal with the phone calls, days away from work, trips across town, attempts to coordinate doctors and other hassles.
“I think, as a health care system, we don’t acknowledge the investment on the patient side,” Koenig told the American-Statesman.
Under the old approach, Koenig didn’t have much of a financial incentive to help them treat their health problems. He made his money performing surgery.
“I got paid to do things to you. I didn’t get paid to take care of you, necessarily,” Koenig said, adding, “I got tired of not being able to help a large number of patients.”
Newer, not bigger
Koenig’s unit can function the way it does — free of many of the economic pressures facing medical providers — in part because “this community said, ‘We will tax ourselves to make this happen,’” said Greg Hartman, who oversees Seton Healthcare Family’s Texas operations.
It is too early to measure the community’s returns on the investment in the medical school. But in late May, the first large-scale, tangible result of that deal will open: The Dell Seton Medical Center will replace Brackenridge, historically the hub of medical care in Austin.
Dell Seton will serve an Austin far larger than the one for which Brackenridge was built. But the new hospital, which is next door to the old one, has only marginally more capacity and actually has less square footage. Officials point to important symbolism in that decision.
The idea is that health care should be set up to keep people healthy enough that they don’t need to go to the hospital, said Hartman, who once ran the old hospital. One example of the long-term plans: getting clinics into the various corners of the community, such as in H-E-B grocery stores, where patients can go for simple procedures such as blood work. Hartman said a clinic in the H-E-B by Bee Cave Road and Loop 360 allows patients to talk with a specialist through a video screen.
“It’s a little bit of the Starbucks model, with a lot of access points,” he said. Ease of access, he added, is intended to entice people to keep an eye on their health and identify issues before they become hospital-worthy.
But this is where the “patient-facing” side of the health care system collides with the behind-the-scenes economics. Health care has been based on a “fee for service model,” in which doctors are paid for the amount of work they do. Dell Seton will be experimenting with an “outcome-based model” in which, generally speaking, doctors are paid based on the health of their patients.
That philosophy informed the care of Martinez, the patient with sore hips, Dell Seton officials say. In prescribing home exercises before moving to other treatments, Koenig’s team not only saved her the hassle of getting to appointments, but also avoided treatments for which someone – Martinez, the government or an insurance company that passes costs to customers – ultimately has to pay.
Dell Seton officials insist they aren’t looking to cut costs by denying needed treatments. But they do say they want to keep patients healthier as a way to reduce the costs that a treatment such as surgery create.
They also say the way doctors are now paid makes sense at a basic level. Doctors do work and are paid based on having performed those tasks. Even if laws are changed to allow things like Skype appointments, a health care system that pays based on patient health has to answer such questions as, how do you judge a doctor’s or a medical team’s influence on their patients’ health? How do you adjust pay accordingly? How should the care Koenig’s team provides to Martinez and other patients be measured?
In light of such tricky questions, much of the health care industry might balk.
“Transitioning to this new approach is risky” for many health care companies, said Johnston, the medical school dean. “We’re in a good position. We’re free to design a new system, see what works and spread it.”
Return of the home visit
Health care providers say that even with all of the obstacles to change, they have to prepare for it.
“The way consumers are, frankly, demanding change, it was smarter to get out in front of the train,” said Hartman, the former head of Brackenridge.
Even officials with St. David’s Healthcare, which is part of the largest hospital system in the country and has seen enormous profits under the current setup — say they are adding numerous patient-centric features to keep ahead of competitors and prepare for large-scale industry changes, including:
• Publishing emergency room wait times online.
• Online check-in that allows patients to wait at home until a patient room is available, as opposed to waiting in a clinic lobby.
• Nurse-call buttons that let a patient request a specific service, such as help using the restroom, rather than an all-purpose button that requires nurses to spend more time visiting the patient before finding the appropriate person to respond.
One of the more substantial changes is the addition of bone marrow stem cell transplants to local treatment options. A local 2014 bone marrow stem cell transplant was hailed as a major addition to a health care system scrambling to keep up with Austin’s growth. Before then, that treatment — along with many other types of cancer treatment — often required Austin patients to move to Houston, Dallas or other big cities for months or more, further disrupting lives already turned upside down by cancer.
Austin’s growth has drawn the eye of Baylor Scott & White, which is expanding into the region. Its new downtown clinic — the one Kauhl now relies on for his prostate cancer treatment — is partly the product of the realization that health care should adopt technology that has long since made many services more convenient.
“For a very advanced industry where miracles happen daily, health care for some reason has not embraced information technology” to improve a patient’s experience, said Nick Reddy, Baylor Scott & White’s chief technology officer. “The reality is health care is not convenient in the way most services are.”
For all the conveniences that the clinic offers — sleek designer seating, iPad-like interfaces that display estimated wait times, a smartphone app that lets patients fill out paperwork in advance at home — one change symbolizes the general approach Baylor Scott & White is trying to take, its executives say: home visits.
The clinic’s supervising physician, Skye Clarke, keeps a backpack loaded with medical supplies for home visits. In most cases, Clarke said, she is willing to make visits within a 10-mile radius. It is a return to an old tradition – doctor house calls – but is also extra work for people in a profession in which customers have had to adapt to a doctor’s timetable.
All of the people who work for Baylor Scott & White understand that schedules and services will be increasingly offered on patients’ terms, Reddy said.
Reddy said most employees are amenable to that idea and cognizant that technology hasn’t made medicine much easier to deal with for the average person over the past half-century. How could someone have a pizza delivered quickly and cheaply to any ZIP code in the United States, Reddy mused, but still have to drive to a pharmacy or wait weeks for an order of essential medicines to arrive?
“We are not an industry that is known as consumer-friendly. We are well aware of that,” Reddy said. “And we are trying very hard to change that.”