Karen Davis, PhD, has paired her interest in statistics and economics with her desire to improve the healthcare system. A former president of the Commonwealth Fund, she has been able to influence many important pieces of healthcare legislation, including the landmark Patient Protection and Affordable Care Act.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
Growing up on a wheat farm in Ponka City, Okla., a small town about 100 miles north of Oklahoma City, Karen Davis, PhD, was raised with "that basic Midwestern ideal value system that you try to help people out, and you use the talents you've been given to do that."
Davis, who is a professor in the Department of Health Policy and Management, and director of the Roger C. Lipitz Center for Integrated Health Care at the Bloomberg School of Public Health at Johns Hopkins University, was actively involved in 4-H as a girl, which she says rounded out her philosophy on life. That, combined with her early interest in statistics and economics, has led to desire to improve the healthcare system in this country and everyone's access to it.
"The first 'H' is for the heart, which represents that you have a commitment to justice. The second 'H' for the head represents a commitment to scientific approaches. Hands demonstrates a commitment to service and helping people, and the fourth 'H' is for health," says Davis.
Having worked in health policy and reform for more than 40 years, Davis is excited about where healthcare is headed today. She got her start in economics, eventually earning a PhD in economics from Rice University. While at college in 1960s, Davis was influenced by the social movements that were taking place.
"At that time, economics was all about opportunity for people to be educated, healthy, and to work and be contributing members of society, so my early professional career was really shaped in an era of commitment to civil rights, social justice, equity, and opportunity. As I finished my studies I moved specifically into the health field and focused on how to apply all of those concepts," says Davis.
Five years after the passage of Medicare, Davis worked as an assistant professor of economics at Rice University in Houston and a senior fellow at the Brookings Institution in Washington, D.C. She studied the impact of that legislation and became very interested in the difference Medicare made in helping improve access to care for the elderly and particularly minorities and those with low incomes. For her research work, she was elected to the Institute of Medicine, as one of its first female members, in 1975.
In 1977, Davis served as deputy assistant secretary for health policy in the Department of Health and Human Services during President Jimmy Carter's administration. She worked on expanding Medicaid to pregnant women and children and tying eligibility to the poverty level, which eventually became law starting with expansion in late 1980s and early 1990s.
Davis returned to academia in 1981 as a professor of economics and chairman of the Department of Health Policy and Management at the Johns Hopkins School of Public Health. She continued to research effective strategies for healthcare cost containment, and through teaching, she says, tried to convince more students to go into the field of health policy and economics.
With a background in economics, Davis absolutely believes in the power of comparative data to change minds and inform policy. In 1992, Davis began to work for the Commonwealth Fund, the private foundation established in 1918 with the mission to "promote a high-performing healthcare system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults."
From 1995 to 2012, while Davis served as the president of The Commonwealth Fund, she was frustrated with how the U.S. healthcare system compared internationally with systems that not only provided higher rates of healthcare coverage for their citizens, but managed to afford it.
In 2005 she established the Commonwealth Fund Commission on a High Performance Health System. The comparative outcomes and quality of care data the Commonwealth Fund put forth demonstrated that the United States clearly did not have the best health system in the world. Davis says this comparative research on international systems helped to "motivate and create the will for change" in Congress.
The timing of her leadership at the Commonwealth Fund was particularly influential in the development and implementation of the Patient Protection and Affordable Care Act. The foundation funded research focused on strategies to improve access to care and to help pay for that care by improving quality and lowering costs. The foundation's efforts timed particularly well with a Congress and a president willing to make health reform a national agenda priority.
"We had an opportunity to get the right information into the hands of those who can implement the change. The strategy was both in knowing how to anticipate the issues but also knowing at what time to have things ready. When the window of opportunity opened up and President Obama made the surprising decision to say to Congress 'You come up with a plan,' we had a plan ready when that moment in time came," says Davis.
In 2009, Davis was heavily involved maintaining the momentum of the PPACA. She moved to Washington, D.C., and worked with Congress on the implementation of the healthcare law, she says, responding to every invitation to attend briefs and meetings. Earning herself the nickname, "Johnny Appleseed," Davis traveled domestically during this time to "spread the message of innovation." She shared models of care she had witnessed internationally with leaders of large U.S. health systems to help establish best practices in this new era of reform.
"I find that in between government and academia, the foundation world is really the bridge," says Davis. "Being in the foundation world is about figuring out what are the big issues ahead and what do people need to know to make informed decisions and how to effectively communicate that to people in the position to effect change."
Having retired from the Commonwealth Fund in 2012, Davis returned to a career in academia and research at Johns Hopkins, working on what she anticipates will be the next big policy issue. Her current research centers around integrated care, she says, and explores how to better finance not only acute care coverage but also long-term care so "people have the opportunity to age without going bankrupt."
"I think it's the most exciting period in healthcare probably ever in the United States," says Davis. "When I talk with healthcare leaders, it's obviously challenging adapting to a new way of caring for the population, but it's the greatest opportunity to do what we went into healthcare to do, to see people get the care they need but do it in a way that's best for patients and do it in a way that's best for society."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Karen Davis, PhD.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
"I think it's the most exciting period in healthcare probably ever in the United States."
Growing up on a wheat farm in Ponka City, Okla., a small town about 100 miles north of Oklahoma City, Karen Davis, PhD, was raised with "that basic Midwestern ideal value system that you try to help people out, and you use the talents you've been given to do that."
Davis, who is a professor in the Department of Health Policy and Management, and director of the Roger C. Lipitz Center for Integrated Health Care at the Bloomberg School of Public Health at Johns Hopkins University, was actively involved in 4-H as a girl, which she says rounded out her philosophy on life. That, combined with her early interest in statistics and economics, has led to desire to improve the healthcare system in this country and everyone's access to it.
"The first 'H' is for the heart, which represents that you have a commitment to justice. The second 'H' for the head represents a commitment to scientific approaches. Hands demonstrates a commitment to service and helping people, and the fourth 'H' is for health," says Davis.
Having worked in health policy and reform for more than 40 years, Davis is excited about where healthcare is headed today. She got her start in economics, eventually earning a PhD in economics from Rice University. While at college in 1960s, Davis was influenced by the social movements that were taking place.
"At that time, economics was all about opportunity for people to be educated, healthy, and to work and be contributing members of society, so my early professional career was really shaped in an era of commitment to civil rights, social justice, equity, and opportunity. As I finished my studies I moved specifically into the health field and focused on how to apply all of those concepts," says Davis.
Five years after the passage of Medicare, Davis worked as an assistant professor of economics at Rice University in Houston and a senior fellow at the Brookings Institution in Washington, D.C. She studied the impact of that legislation and became very interested in the difference Medicare made in helping improve access to care for the elderly and particularly minorities and those with low incomes. For her research work, she was elected to the Institute of Medicine, as one of its first female members, in 1975.
In 1977, Davis served as deputy assistant secretary for health policy in the Department of Health and Human Services during President Jimmy Carter's administration. She worked on expanding Medicaid to pregnant women and children and tying eligibility to the poverty level, which eventually became law starting with expansion in late 1980s and early 1990s.
Davis returned to academia in 1981 as a professor of economics and chairman of the Department of Health Policy and Management at the Johns Hopkins School of Public Health. She continued to research effective strategies for healthcare cost containment, and through teaching, she says, tried to convince more students to go into the field of health policy and economics.
With a background in economics, Davis absolutely believes in the power of comparative data to change minds and inform policy. In 1992, Davis began to work for the Commonwealth Fund, the private foundation established in 1918 with the mission to "promote a high-performing healthcare system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults."
From 1995 to 2012, while Davis served as the president of The Commonwealth Fund, she was frustrated with how the U.S. healthcare system compared internationally with systems that not only provided higher rates of healthcare coverage for their citizens, but managed to afford it.
In 2005 she established the Commonwealth Fund Commission on a High Performance Health System. The comparative outcomes and quality of care data the Commonwealth Fund put forth demonstrated that the United States clearly did not have the best health system in the world. Davis says this comparative research on international systems helped to "motivate and create the will for change" in Congress.
The timing of her leadership at the Commonwealth Fund was particularly influential in the development and implementation of the Patient Protection and Affordable Care Act. The foundation funded research focused on strategies to improve access to care and to help pay for that care by improving quality and lowering costs. The foundation's efforts timed particularly well with a Congress and a president willing to make health reform a national agenda priority.
"We had an opportunity to get the right information into the hands of those who can implement the change. The strategy was both in knowing how to anticipate the issues but also knowing at what time to have things ready. When the window of opportunity opened up and President Obama made the surprising decision to say to Congress 'You come up with a plan,' we had a plan ready when that moment in time came," says Davis.
In 2009, Davis was heavily involved maintaining the momentum of the PPACA. She moved to Washington, D.C., and worked with Congress on the implementation of the healthcare law, she says, responding to every invitation to attend briefs and meetings. Earning herself the nickname, "Johnny Appleseed," Davis traveled domestically during this time to "spread the message of innovation." She shared models of care she had witnessed internationally with leaders of large U.S. health systems to help establish best practices in this new era of reform.
"I find that in between government and academia, the foundation world is really the bridge," says Davis. "Being in the foundation world is about figuring out what are the big issues ahead and what do people need to know to make informed decisions and how to effectively communicate that to people in the position to effect change."
Having retired from the Commonwealth Fund in 2012, Davis returned to a career in academia and research at Johns Hopkins, working on what she anticipates will be the next big policy issue. Her current research centers around integrated care, she says, and explores how to better finance not only acute care coverage but also long-term care so "people have the opportunity to age without going bankrupt."
"I think it's the most exciting period in healthcare probably ever in the United States," says Davis. "When I talk with healthcare leaders, it's obviously challenging adapting to a new way of caring for the population, but it's the greatest opportunity to do what we went into healthcare to do, to see people get the care they need but do it in a way that's best for patients and do it in a way that's best for society."
In our annual HealthLeaders 20, we profile individuals who are making a difference in healthcare. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in the evolution of healthcare. This is the story of Harlan M. Krumholz, MD, SM.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
"In the end, it was always about whether our work was likely to result in something that would benefit the patients or population."
When pharmaceutical and medical device companies align with physicians, sometimes the patient is seen as the third wheel. One cardiologist and researcher at Yale University School of Medicine is trying to change that. Harlan M. Krumholz, MD, SM, credits the collaborations he's made for advances in industry transparency and patient safety innovations, not biased prescriptions or ignored patient interests.
In June 2013, Medtronic, the medical device giant, released the findings of two research groups it commissioned, led by Krumholz, which investigated the company's back-surgery device Infuse. The two research teams concluded the device was no more effective than an older technique but also carried additional risks to the patient. These findings were released to the public immediately. This corporate experiment in transparency is exactly the kind of relationship Krumholz enjoys being a part of.
"My philosophy was always to work to develop strategic partnerships. Bring the science and clinical perspective to work with people eager to bring other perspectives and data. It was never about negotiating access to the data," says Krumholz. "We were always trying to figure out how to work in a collaborative or collegial way. In the end, it was always about whether our work was likely to result in something that would benefit the patients or population."
Whether examining care coordination or communication at the point of discharge, as the director of the Robert Wood Johnson Clinical Scholars Program at Yale and director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation, Krumholz has shined a light on outcomes-based quality metrics with a focus on collaboration and transparency. His work has directly led to improvements in the use of guideline-based medications, the timeliness of care for acute myocardial infarction, public reporting of outcomes measures, and the current national focus on reducing the risk of readmission.
Over the years, that initial collaborative effort at Yale has expanded to include a lot of strategic partnerships and "good friends" working with the center to try to make a difference.
"By working together, we can make sure we promote the common good and avoid the potential for unintended adverse consequences," says the cardiologist.
Krumholz is pleased with where healthcare is headed today. Hospitals are beginning to learn from one another and share best practices as the industry grows and expands. The industry is having conversations it never would have had five years ago, he says.
After graduating from Yale College, Krumholz took advantage of traveling fellowships in 1981, studying models of rural healthcare delivery in the United Kingdom, India, and China. The simple ways healthcare could shift in its delivery and dramatically impact a population influenced him greatly at this early point in his career.
"It sensitized me to think about what results are being achieved by all different types of healthcare systems and the variety of experiences individual patients can have with that system," says Krumholz. "In medical school, we're trained that our job ends when someone goes out the door in a hospital. We are told our job is to reduce the census and help people move out of the hospital, but patients think in terms of episodes and they aren't done with that episode when they go home."
After medical school at Harvard University in 1985, Krumholz served as an internal medicine resident at the University of California San Francisco and later decided to specialize in cardiology in part because he felt the field offered a breadth of opportunities; but the field was also attracting a lot of physicians and there "was a lot of action." He became more and more excited about combining science, data-based research, and policy studies to do work that would help clinical decision making not only at the bedside, but that also would help guide larger policy questions to reshape the industry.
Beginning in 1995, Krumholz also started a series of projects that revealed readmissions as a problem and tested interventions to reduce patient risk. This work placed readmission in public view and later work, with the Centers for Medicare & Medicaid Services, resulted in national measures that were publicly reported and subsequently incorporated into the Patient Protection and Affordable Care Act.
In 2004, Krumholz's work with timely treatment of heart attacks showed that only 33% of heart attack patients were receiving angioplasty within 90 minutes of their admission to the hospital. With National Institutes of Health funding, he pioneered methods to study top performers, including combining quantitative and qualitative studies that contributed to a national campaign to translate the research into action. Within three years more than 90% of patients were treated within guideline recommendations.
Krumholz credits his teams at the university, the hospital, and the Robert Wood Johnson Foundation as the force behind his contributions to the way healthcare is delivered in the United States today. Krumholz's team at CORE has expanded to include a lot of strategic research partnerships over the years, including insurers, Medicare, and the medical device and pharmaceutical industries, where he says his team is trying to make a larger difference in the market through studying best practices to influence clinical decision making.
"It isn't just about understanding why the provider is making the right or wrong choices, but also figuring out how to ensure that high-quality decisions are being made. There's an unlimited opportunity in the market to affect performance and make the system more responsive," says Krumholz. "I saw the best opportunity to impact practice was to produce knowledge that could be immediately applied."
When Krumholz began his research on readmissions, there was no incentive in the industry to pay attention to the rates at which patients were returning to the hospital. Despite their findings, Krumholz and his team were searching for subjects and participants, but hospitals didn't adopt their initial findings "because there was no incentive to do it." Almost no hospitals that did participate in the readmissions pilot program continued.
"You only have to look closely at the lack of systems we have in place that truly help people make a transition to realize how broken this system is. Anyone who has been in the hospital knows that returning home is a rocky transition and usually little is done to help them," says Krumholz. "Readmission rates are starting to drop but it will take several years to replace a mind-set that's existed for decades."
Healthcare providers need an ICD-10 strategy that includes adequately training medical coders and retaining them in their jobs. With an already extremely low unemployment rate, ICD-10 coders will be very much in demand.
With the ICD-10 deadline a year away, hospitals and health systems are ramping up their staffing strategies to hire, train, and retain their medical coding workforce in time for next year's transition. But there are challenges to retraining a coding staff onto a system that's more complicated than the previous one, and to keeping those coders around once they're trained and in demand.
In September, the American Association of Professional Coders released its 2013 Healthcare Salary Survey, which reflected a rise in medical coder employment and a steady pay increase over the past three years. Certified professional coders (CPC) have a 1.7% unemployment rate, nearly half the rate last year.
With the shift to ICD-10 coming next year, providers need to have a plan so that they adequately train, but don't lose coders. Four steps are essential.
1. Manage productivity expectations
Angie Mannon, Senior Vice President of Human Resources at Inova Health System in Virginia spoke with me about the strategies Inova has implemented to prepare its coding staff of approximately 120 for the ICD-10 deadline. Mannon is in charge of hiring and retention strategy.
"I just hope the date doesn't change again. Having the date delayed cost us in some productivity. We had everything ready to go and had scheduled the training," says Mannon. "But because the deadline got pushed back, we didn't want to have people start training on the same thing for two years. You don't want people toggling back and forth between ICD-9 and ICD-10."
Inova is giving time during the normal work day for its coders to train and practice on ICD-10, but productivity targets have been adjusted to allow for this transitional period. "It's important to figure out what it would take for existing coders to work at the same level of proficiency they have now, so productivity wouldn't be affected," says Nelly Leon, director of coding and classification at AHA.
"I've heard that hospitals have plans to get their production coders to get an early start before they have to submit it externally so they can practice areas for additional training before they go live."
"What we're more worried about is accuracy than speed," says Manning.
2. Provide schedule flexibility
"Most of the concern is the learning curve associated with the transition to ICD-10," says George Argus, who works with medical coding and classification strategies for the American Hospital Association. "This learning curve will probably slow down the volume that coders typically would handle. Additional staff might be needed and additional overtime will probably be needed to meet the compliance standards."
"We recognize that learning this new system is extremely involved, so it is going to encroach on overtime and vacation time," says Mannon. "We have a limit on the length of vacations workers can take. Our PTO caps typically, but right now we don't cap after a certain accrual level for our coders." According to the AAPC survey, approximately 75% of medical coders work more than 40 hours a week.
Inova also provides a retention bonus for three years. Employees sign a retention agreement and every year they stay, they get a bonus.
"It helps us maintain our very little turnover. At our system it's less than 5% for coders, and that is way lower than our organizational turnover, which is 12%. Coders also get to work remotely, so we allow a lot of flexibility with coding staff, which helps." But hospitals are beginning to look over their shoulders.
3. Stay competitive in the market
According to the AAPC survey, medical coder jobs are increasing nationally in number and being filled regularly. Salaries also increased at unprecedented rates in 2012, according to the AAPC survey.
"Good coders are always hard to come by, even in the existing environment. So it doesn't surprise me that hospitals would take innovative approaches for vacation time or salary to handle the implementation phases and learning curve associated with that," says Argus. "Retention is a reality and I think they have to be adjusting."
Because the ICD-10 skill set hasn't quite met a demand in the market, at Mannon says Inova hasn't lost a single coder to another organization. But the provider is conducting weekly salary benchmarking reports, so it can keep pace and stay competitive.
4.Control resistance from older workers
Another cause for employers' concern: coders near the end of their careers may be intimidated by learning an entirely new system.
Mannon says a large part of retaining retirement-age workers is managing that fear. One of the key implementations was computer-assisted editing software, which suggests answers for coding and takes away a fear of inaccuracy.
"It's really computer literacy more than it's an age issue. The delay of ICD-10 put fear in the coders that didn't need to be there. Anecdotally, I would hear that they thought because of the delay that the coding was more difficult than it is. I think you view things like that from the seat you sit in. People are thinking this is more complicated than it is, when ICD-9 and ICD-10 really aren't that different."
"There is never a good time to introduce change. And it's always costly to deal with it. We've been given a year and we're trying to communicate to our members to make sure they are on schedule with where they need to be. It's tough to maneuver through those various activities and make the transition successfully," says Argus. "There will be some pain as a result of the transition, but we want to minimize that."
Your most powerful recruiting tool is the message you're broadcasting on social media. Recruiters should be in lockstep with the marketing department if they hope to compete with other organizations to recruit and retain potential employees.
Why do the top health systems attract the best talent? That's easy. Their reputations precede them. And increasingly that's happening via Facebook, LinkedIn, Twitter.
A candidate's initial web search can lead to a stone wall. A general homepage, with a fairly informative careers page lack any flavor, character, or buzz to excite applicants. Maybe there are some jobs posted. Whoopee.
"When we're talking employer branding, social media is the purest way for an organization to distribute their brand," says Shawn Kessler, senior strategist at ab+c, a marketing communications agency. Kessler heads up recruitment and marketing division within the agency, and specializes in healthcare. Eighty to ninety percent of his work leans heavily on employer branding efforts.
Let's take an honest look in the mirror.
Here are the three negative messages of your bare-bones social media presence:
1.You fail to set yourself apart from any other hospital or health system.
What's worse than an applicant being unable to find any insight into your employee culture? The fact that you actually do all of these things: the picnics, the run/walks for charity, employee concerts, but no one knows because you don't post about these events on social media. You look like everybody else.
With all of the photo-sharing capabilities, Facebook is a great resource for a job seeker to investigate day-to-day life and brand messaging of a future employer. It's also a great way for employers to stand out from the crowd.
Facebook's company page has 95703934 "Likes," From charities to appreciation days to celebrity concerts at the office, it's full of posts about employee events. The company is letting the world know how much it values its employees.
2.You fail to attract the right kind of jobseekers:
Applicants follow their dream jobs on LinkedIn.
Like it or not, when young physicians, nurses, and even nonclinical staff are looking at where they want to start their professional careers, they're more likely than ever to start their research with your company LinkedIn page.
Unfortunately, your former employees are more likely to show up than your non-existent LinkedIn presence. When you search a company on LinkedIn, profiles of past and present employees display. The length of their tenure, what company they moved on to next—all of this information is leaving impressions on your talent pool.
"Anytime we can get a physician willing to put their own name on something, or they're willing to let us tag them in a video, that shows up on their social media profiles. Those colleagues they're associated with and did training with are going to see that," says Kessler. "We want those folks talking about the organization in a way that's going to be in front of their friends and colleagues, showcasing their work. Because that's how you attract that additional talent pool."
Employees want the company brand their stamped with to carry on as a positive beacon to future employment opportunities. They want to get a sense of the kind of people they might be working with, and where this job may lead them in the future.
"LinkedIn has yielded a lot of success on the corporate recruitment side," says Jeff Lowry, senior corporate recruiter at Geisinger Health System in Danville, PA. Social media and job postings make up approximately 35% of their recruiting efforts.
"We've been driving a lot of candidates to our career site through our LinkedIn page. It's been really successful there for marketing, sales, and insurance professionals. That's where our best return has been. Our strategy moving forward is to incorporate all areas of talent acquisition here."
LinkedIn's own company page has more than 500,000 followers. With a careers page including day-in-the-life videosand messages from executives, job applicants get a thorough picture of what it's like to work at LinkedIn.
3.Your employees aren't proud brand ambassadors.
"Organizations that have a strongly engaged population of employees on social media, I think those employees are proud of their employer and the work they do," says Kessler. "It sends the message that they genuinely believe their organization helps people, and I think they're proud of that. Employees can be a little skittish, but those that believe their organization is there, doing the right thing, I think those employees are likely to stand up and defend what they do."
At Twitter, the San Francisco headquarters has its own handle, @Twoffice. The account actively ReTweets and shares employees' tweets and highlights from their workdays. From movie screenings to celebrity visitors to new signage and birthday parties, the company culture is out there for the world to see.
Without this social media presence, you leave applicants to wonder: If your company truly has a great employee culture, and people enjoy working there, then why aren't they shouting it from the rooftops?
When employees share positive moments from their work days, companies reap the rewards in a positive and healthy brand message, as authentic as the employees themselves.
Encouraging healthcare workers to get their flu shots has been a patient safety and quality of care issue for years. Mandatory public reporting of this hospital quality measure is finally moving the needle.
On October 1, while everyone was buzzing about whether or not they could get past the technical glitches on health insurance exchanges, the 2013–2014 flu season officially began.
This year flu season is different. This year, it's not only hospitals, but acute care and long term care facilities that must report staff vaccination rates to the Centers for Medicare and Medicaid Services or risk being penalized. The data will be posted on Hospital Compare.
Last flu season, 72% of healthcare personnel reported having had a flu vaccine, a 5.1 percentage point increase from the 2011–2012 season. Hospital-based employees had the highest vaccination rate (83.1%) and long-term care employees had the lowest vaccination rate (58.9%).
For North Shore-LIJ Health System's more than 46,000 employees in hospitals across Queens, Staten Island, Long Island and Manhattan, federal reporting appears to have helped improve vaccination rates.
During the 2012–2013 flu season, 68% of the staff at North Shore-LIJ were vaccinated, 27% declined, and 1% were medically exempt. In the 2011–2012 flu season, 58% were vaccinated, 16% declined, 0% were medically exempt, and the status of 26% of employees was unknown.
Infrastructure Matters Because of the CMS reporting requirement, North Shore-LIJ had to make a big push to document the status of its employees. Lorraine Chambers Lewis, assistant vice president of employee health services at North Shore-LIJ, says NSLIJ's intranet infrastructure was essential to effectively tracking and tallying their compliance with CMS's new rule.
"If you don't have the infrastructure already there, this is extremely difficult. The data gives the leaders the information and gives the department heads and managers something to react to in order to engage folks. Without it you don't really know where you are. The data is so important," Lewis says.
The intranet reports allowed managers to know exactly where their direct reports stood with regard to the flu vaccine. Lewis attributes this level of individual accountability for increasing the health system's vaccination rate by 10 percentage points.
"Human resources played an extremely important role in making this happen. They were a critical aspect from compliance and communicating to managers. Questions and concerns about compliance all went through HR, as well as the strategies to make sure compliance happens overall. That's how we got to 96% reporting their status last year," Lewis says.
Last year, there were some concerns at North Shore-LIJ about pockets of employees who traditionally had low vaccination rates. Nationally, different cultural groups perceive vaccinations differently. For example, CDC data for the past three years shows that vaccination rates for non-Hispanic whites were higher than for non-Hispanic blacks, Hispanics, and adults of other or multiple races.
At North Shore-LIJ, a task force enlisted the help of the diversity officer to make sure those employees had background and education on what's available, why it's important for their health, as well as the safety of the patients.
Strategy Shift to Top-Down Team Approach "We tried to make sure we address those folks' concerns and discuss any cultural issues that might exist," says Lewis. "We really wanted to make sure we addressed the needs of anyone. If any group was very hesitant, we wanted to be sure we could engage with them."
Running through each of these elements was the key strategy shift: Engage a top-down team approach. Executives at all the North Shore-LIJ sites leaders were held accountable with the data before them. They enlisted and empowered their managers with this data as well to ensure that system-wide communications were reaching the individual employees.
"The main message was, 'We all care. About your health and well being, as well as our patients.' The goal for the strategy was that for every employee, someone is speaking to you and reaching out to you. To do that we had to have educated and enlisted managers," says Lewis.
This year North Shore-LIJ started its employee campaign to get workers vaccinated in early September. One month later, 53% are vaccinated, 3% have declined, and 0% have reported a medical exemption. With 56% participating so far, the health system is way ahead of where it was last year.
It looks like it does take a little bit of mandating to create lasting change. Especially when needles are involved.
Federally mandated cuts to Medicare and Medicaid hospital payments for uncompensated care go into effect on schedule, but hospital associations and lawmakers are actively proposing their delay.
The federal government may have shut down overnight, but provisions and funding cuts mandated by the Patient Protection and Affordable Care Act to be effective October 1 are rolling out as planned.
Much attention has been directed at the opening of the health insurance marketplaces, but Oct. 1 is also the day that the Centers for Medicare and Medicaid Services begins cutting Medicaid and Medicare disproportionate share hospital payments.
The loss of these monies, which compensate hospitals for the cost of treating the poor and uninsured, is expected to take a significant financial toll on many hospitals. But a bill introduced September 27 by Sen. Roger Wicker (R-MS) would delay the PPACA cuts to both the Medicare and Medicaid DSH payments.
Supported by the American Hospital Association, the bill is a companion to the DSH Reduction Relief Act (H.R. 1920) proposed by Rep. John Lewis (D-GA) in May 2013, which suggested DSH payment cuts be delayed for three years.
"Delaying the DSH cuts will help ensure that hospitals that serve high volumes of uninsured patients can continue to provide needed services to their communities," said Rick Pollack, executive vice president of the American Hospital Association in a prepared statement. "Maintaining DSH payments is vital to hospitals that care for the uninsured. We look forward to working with Congress to delay the reductions and provide vital support for hospitals that serve the most vulnerable."
In 2012, the Medicaid DSH payments for all states and the District of Columbia were estimated to be $11.34 billion. CMS will reduce Medicaid DSH payments by $500 million in FY 2014 and $600 million in FY 2015, increasing annually. The program will face cuts of $5 billion in 2018, $5.6 billion in 2019, and $4 billion in 2020.
America's Essential Hospitals, formerly the 200-member National Association of Public Hospitals and Health Systems (NAPH), has been advocating in Congress for an improved DSH payment system that reflects the reality of the front-lines of care today. The hold-up, reflecting much of politics today, has been largely political, says Shawn Gremminger, assistant VP of legislative affairs at America's Essential Hospitals.
"Politics gets in the way. We often hear back 'I agree with you, I see there's a problem.' But in Republicans' cases they often say my boss opposes the PPACA, and we want a wholesale change. The Democrats' response is typically 'I'd like to help, but with Republican attacks I can't afford to do anything that changes the PPACA, and we need to defend the law in its entirety," said Gremminger.
"Any legislation at all around healthcare is just toxic. There's very little that both sides agree on."
America's Essential Hospitals is advocating for Congress to delay DSH payment cuts for three years, as well as realign the reimbursement formula to be more "evidence-based" or more accurately reflect the reality of uncompensated care at each state.
In 2010, the average hospital margin of America's Essential Hospitals members was 7%. For the nation's largest urban hospitals, the proposed DSH payment cuts would put their 2% profit margin closer to -7%, AEH calculates.
Medicaid DSH payments to hospitals in FY 2014 and 2015 will be allocated based on data that predates state decisions on Medicaid expansion, according to the May 2013 CMS rule on DSH allotment reductions. According to CMS data, 10.8 million Americans reside in states where Medicaid is currently not planned to be expanded by 2014. By 2014, 8.7 million new beneficiaries are expected to enroll in Medicaid.
The reductions will more heavily impact states that don't direct DSH payments to hospitals with high volumes of Medicaid patients and uncompensated care. Reductions will also more greatly impact states with lowest percentages of uninsured.
New York, a state that is more heavily dependent on DSH payments with its high numbers of uninsured, is expected be most dramatically affected by the cuts. But advocates are most worried about hospitals in states without Medicaid expansion.
For the 2014 fiscal year, which begins Oct. 1, CMS will begin to reimburse hospitals under its new formula for Medicare DSH payments, as outlined in the 2014 Hospital Inpatient PPS final rule released in April. Hospitals will begin to receive 25% less from Medicare for treating uninsured patients than they received previously.
"The 2014 cuts to DSH aren't necessarily going to be closing hospital doors, but the margins are so narrow that our hospital would have to look around to see areas where they are losing money and stop doing those things. There will probably be cuts to outpatient clinics, a reduction in community efforts, or ancillary services. But 2018 and 2019, when 5 to 6 billion will be cut to DSH payments, many of our hospitals simply aren't viable at this point," Gremminger said.
Access to real-time scheduling data helped one New York state health system cut overtime hours in half in just one year.
It happens at every hospital. A nurse at the end of her shift is asked to pick up the shift of a colleague, who has just called in sick. The nurse is tired, having worked three back-to-back 12 shifts, but agrees, eager for the overtime pay.
Unfortunately, the nurse manager has no way to quickly determine that four other nurses could have fit the additional shift into their schedules without pushing into overtime.
A hospital's labor force is the largest piece of its budget and improper management and scheduling can have a large impact on a hospital's bottom line.
Ellis Medicine, a 450-bed health system based in Schenectady, NY, empowered its managers with real-time scheduling information to effectively and efficiently staff their units. And by providing the same up-to-the-hour scheduling information to every employee, Ellis extended intelligence on staffing issues system-wide.
"Unscheduled absences are a challenge for all organizations. What's key is to know ahead of time what our schedule is, where people are, and when they will be here," said Joseph Giansante, vice president of human resources.
"By providing that information in real time, a manager can make immediate adjustments. With systems in the past you didn't have this data, and you find out you have issues in the pay period, two weeks beyond being able to do anything about it."
The scheduling system Ellis uses from an outside vendor allowed all departments and employees to have access to the same scheduling data through a coordination of its HR, IT, and finance departments. After running the pilot in the inpatient units, Ellis rolled the system into nonclinical areas, including food services and environmental care.
The three-hospital system and teaching facility was able to reduce compensation costs for its 3,300 employees by 40% without understaffing any units, all through managing, and reducing, unnecessary overtime costs over a six month period.
Over the first year of implementing the system, Ellis cut overtime hours in half. This resulted in a savings approaching $2 million for overtime compensation, not to mention unseen costs saved in the patient safety arena due to a fatigued workforce.
"We created an individual staffing dashboard. So for each unit, and this is real time, anybody can go on our intranet, pick a particular unit at a particular time of day and find out what was the staffing model that day and that unit," says Giasante. "They see any unscheduled absences, or what was the ratio of employees on the unit to the patient. Any employee, manager, can go on there and check that out. That's ultimate transparency."
Giasante says this leads to an improved sense of teamwork on the department level. Employees are less likely to take unscheduled absences when anyone in the hospital can look up why a particular floor was short-staffed, and data is updated to the hour.
Within two years, the scheduling module paid for itself, says Giasante. Retention has increased and turnover has gone down by almost 10%. Three years in, employees surveyed reported higher job satisfaction levels.
"So many scheduling issues for managers are managed just by having data. Without that, a manager, to his or her credit, [has] to run [his or her] departments, things come up and they have to use their people and if we don't give them the tools to manage these schedules, then shame on us," says Giasante.
The healthcare law is a convenient scapegoat for hospitals looking to downsize staff and reallocate labor costs to other initiatives. Meanwhile, feds mandate home health workers' minimum wage and OT pay.
In this week's healthcare HR news round-up, hospitals and the media are blaming major layoffs on the PPACA when they're simply restructuring. Home healthcare workers win federally mandated minimum wage and overtime pay, while executives and nurse managers are outed for stealing from patients, and a regular citizen pretends to be a hospital worker.
Hospitals lay off workers, blame the PPACA
Hospitals are blaming healthcare reform for business shifts that are important to improve the quality and efficiency of our healthcare system. The Patient Protection and Affordable Care Act is just giving many hospitals an excuse to lay responsibility for strategically motivated layoffs on someone else.
Last Wednesday morning, Cleveland Clinic President and CEO Toby Cosgrove, M.D., announced to his 44,000 employees that there would be an unspecified number of layoffs as a part of an effort to reduce the health system's 2014 budget by $330 million, or 6%.
Cosgrove cited the PPACA as one of the reasons behind the cuts, singing a similar tune to the dozens of other hospitals across the country that have announced layoffs in recent weeks and blamed the law.
These budget cuts and layoffs aren't holding back hospitals and health systems from making investments in other areas, such as mergers and acquisitions or facility upgrades. At the same time that Cleveland Clinic is cutting $330 million, it has formed a tentative deal with Community Health Systems to acquire Akron General Health System.
As the Clinic's spokesperson told the Akron Beacon Journal, "This can't all be about cost-cutting. We have to grow."
Three stories were in the news last week about hospital workers, and wannabes, behaving badly. This kind of news makes patients nervous about who is treating them, and wonder who is in charge.
A lawsuit filed in 2011 by former employees, released in federal court last week, accused leadership at Vanderbilt University Medical Center of committing Medicare fraud for decades.
Jeff Balser, M.D., Ph.D., the head of VUMC, is accused of being the ring leader. The suit claims Balser, who worked in the anesthesiology department at the time, collaborated with other physicians to design software that perpetuated its illegal billing practices through its medical records system. VUMC is vehemently denying the allegations.
Meanwhile, in Syracuse, NY, a 20-year employee of St. Joseph's Hospital Health Center plead guilty last week to the accusation that she stole $900,000 from patients for over 11 years at the hospital. She allegedly stole money from patients who thought they were paying for television and phone services.
What's the difference between Bonnie Simson, a former nurse manager at the hospital, and Nurse Jackie? Simson isn't accused of stealing narcotics from the hospital, but she was using the money to pay for her painkiller addiction, which cost her between $900 and $1,500 a day, the Post-Standard reports.
Grant Medical Center in Columbus, OH, is watching its hallways a little more closely this week after a woman posing as an employee was reported wandering near the maternity and infant care wings last week. Hospital security assured the local community that the trespasser, who was wearing scrubs and a stethoscope, was unable to access the care unit. In both instances, the woman was escorted from the hospital and hospital officials have filed a criminal complaint.
Minimum wages and OT mandated for home health workers
Last Tuesday, the Department of Labor's Wage and Hour Division approved the final rule expanding the Fair Labor Standards Act's minimum wage and overtime protections to home health care workers. Two million direct care workers, home health aides, personal care aides, and certified nursing assistants will be affected by this change, a group whose work falls under "domestic services" and whose federal labor laws haven't been updated in 38 years.
Direct care workers remain one of the lowest-paid sectors of the service sector, and so improving their training, as well as the quality of the care provided by these workers, was becoming increasingly difficult.
Effective January 1, 2015, the exemptions to minimum wage for those who simply provide "companionship services" now can only be claimed by individuals, and no longer by staffing agencies. Those workers are defined as individuals who are hired primarily for companionship, protection, and basic care needs by an elderly individual or their family, now excluding any direct care workers who provide services that require medical training.
The overtime pay protections can substantially raise the salaries of these workers, who often work long hours to care for people needing independent, round-the-clock care. Medicare and Medicaid costs are expected to increase by under three-tenths of 1% of what federal and state governments spend on the program.
The final rule, according to the Department of Labor, reflects the trend that more elderly wish to have their medical care provided at home instead of a nursing or long-term care facility, and increasingly rely on home care professionals with medical training.
Human resource executives at hospitals and health systems say planning for healthcare reform is their top priority, but the majority of them feel challenged by too many competing initiatives.
With less than two weeks to go until health insurance exchanges , also known as marketplaces, open for business, human resource executives at hospitals and health systems are preparing for a raft of changes that will affect healthcare workers and HR processes.
From improving patient experience to reducing costs, human resource departments are implementing mandates laid out in the Patient Protection and Affordable Care Act by putting them at the top of their hiring, recruitment, and retention priorities.
Survey results released Wednesday tell the tale. The American Society for Healthcare Human Resources Administration (ASHHRA), the professional membership organization of the American Hospital Association, and HealthcareSource, a talent management software provider, collected responses from nearly 500 U.S. healthcare HR professionals and executives in July 2013 about their top HR initiatives. (The report itself won't be released until next month.)
When asked about their top priority for the next 12 months, 64% of senior healthcare HR executives said that planning for the effects of healthcare reform is their top priority, up 10% from last year. Eighty percent of C-suite level executives, 64% of directors and managers, and 56% of HR general staff said preparing for healthcare reform is a top HR initiative.
"Certainly the biggest unknown [for healthcare reform] is the influx of those newly covered patients. Since we don't yet know what the workforce need is to match this, many healthcare organizations' processes are becoming more streamlined so that they have the flexibility to cover more and more people, while continuing to provide high quality care," said Stephanie Drake, MBA, senior executive director at AHA Professional Services, in a media statement.
In fact, 73% of respondents, which represented a range of C-suite executives, directors, managers, and individuals, said their top strategy to reduce costs is streamlining HR processes.
With labor costs representing more than 60% of hospital budgets, the primary focus of hospital human resource professionals to prepare for healthcare reform is to reduce costs.
"There are two sides to the coin. One is cost cutting initiatives, so everyone including HR has to tighten their belts, whether that's in managing their own department or working more broadly with other managers," said Adam Higman, vice president of Soyring Consulting, a clinical and operational consulting firm for acute care hospitals.
"The other side is [that] everyone is still hoping that once the exchanges go up, you'll have a larger patient volume that can also pay for their services. HR folks need to be more efficient now, but also need to plan for the hiring frenzy that's going to occur once that higher patient volume starts to come in," Higman said.
The quality of those hires matters, as well. With the reimbursement structures of the PPACA more aligned with patient experience and the quality of patient care, hospital HR executives are figuring out strategies to not only recruit at a high volume, while keeping costs low, but to make strategic decisions with the patient experience in mind.
When asked about current HR initiatives to improve patient satisfaction 80% of respondents said they are working to improve employee satisfaction, followed by 78% who said they are working to create a culture of employee accountability, and 70% who said they are focusing on improving the patient experience (70%). Survey respondents could choose multiple answers.
To improve patient safety, another key element of the PPACA, 79% of hospital HR professionals said one of their initiatives was to improve workforce education and development, followed by 66% who said they are working to improve employee satisfaction.
The biggest challenge to achieving their HR initiatives is the perception that there are too many competing initiatives 72% of respondents said. Slightly fewer, 65%, said there isn't enough time for projects.