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Despite Challenges, There Are Reasons for Optimism

Message From the Chair

The start of a new year is generally associated with both uncertainty and optimism. 2014 has plenty of both. The principal uncertainty in our professional life is the impact of changes in the healthcare insurance markets driven by the further implementation of the Affordable Care Act. Whether you are optimistic or not depends to a large part on whether you think this is a good or bad thing.

It may be of some comfort to remember that American medical care and, by extension, the business of Cedars-Sinai has already been moving in the direction of increasing value (defined as the relationship between costs and benefits) in most of the things we do. That said, there are many opportunities to further increase efficiencies, ease of access and rational utilization of services. Indeed, focusing on these important measures is our best chance to avoid a situation where high-end services are not available to those who need them. It is ever more clear that if we do not maintain an informed but resolute attitude to doing more with less, others with a fiduciary rather than medical perspective will impose it.

There should be no illusion that this will be easy — only that it is not impossible. The rate of increase in healthcare expenditures has been slowed (see innumerable editorials about "bending the cost curve"). For example, length of stay at our institution has been decreased dramatically by 25 percent (4.07 to 2.97 days) in the last eight years, and many procedures that would have resulted in an inpatient stay have been converted to outpatient or 23-hour stays. This has occurred even though case-mix-adjusted discharges (a measure of severity and activity) have increased from about 79,000 to 95,500, an annual growth rate of 2.37 percent. Even with this improvement, our overall length of stay is greater than the median when compared to other academic medical centers. It is clear we still have much work to do.

Increasingly our hospital has become a surgical hospital. This is good, as most predictors of hospital viability hinge on this trend coupled with an ability to better manage chronic medical conditions in an outpatient setting. Much effort is being directed to reducing the expenses of surgical procedures by improving efficiency and lowering cost in selected high-volume procedures such as joint replacement. Our future will depend on expanding what we have learned in these early efforts to other procedures which appear to be outliers in cost. Unless we are successful in cost control, we will be excluded from the increasing number of "narrow networks" being formed by insurance companies. Reducing our costs will require cooperation across the institution and, most definitely, good will among all our physician entities. In future editions of Sutures and in other forums, we will learn much more about these issues and our Cedars-Sinai Medicine initiative, led in our department by Harry Sax, MD, MHCM.

Another reason for optimism is the remarkable personal and professional qualities of our current house staff. Their enthusiasm is mirrored by the pleasure most of us have in interacting with them in the care of our patients. Further evidence that this is likely to continue is the superb roster of resident applicants in our growing residency programs. These candidates represent virtually every top-flight medical school. In general surgery, orthopedic, urology and CT surgery, between 25 percent and 40 percent of all senior students interested in a surgical specialty apply to a Cedars-Sinai surgical residency.

While the next few years will be interesting in many ways, we can take pride that we have considerable strength in the market and in our academic stature. We can face up to the challenges handed us.

Bruce L. Gewertz, MD
H and S Nichols Distinguished Chair in Surgery
Chair, Department of Surgery
Vice President, Interventional Services
Vice Dean, Academic Affairs