It's one of the great ironies of healthcare human resources.
There is arguably no other labor-intensive industry that is so reliant upon a highly skilled, highly educated, high-cost, and high-in-demand workforce that literally makes life-or-death decisions every day. And yet, in many hospitals and health systems HR remains an afterthought in the C-suite. HR is considered the domain of pencil-pushing functionaries whose job descriptions do not include strategic planning, and who are better suited for tactical tasks and processes.
There is a growing sense, however, that changes in healthcare brought on by the commercial market and by the federal healthcare law, the inevitable and growing shortages of skilled healthcare professionals, and the newfound and measurable importance of patient satisfaction scores for reimbursements will prompt a reassessment of HR in strategic planning.
Stephanie Drake, executive director of the American Society for Healthcare Human Resources Administration (ASHHRA), concedes that healthcare HR has traditionally been "reactive and not necessarily proactive" around long-term planning and other strategic aims.
"It's all over the board. Some of our ASHHRA members are quite engaged at the board level, looking at turnover and performance issues as they relate to patient safety and experience. But we have other members who might be at the board table but they aren't sure what they should be contributing," she says.
That mindset must change.
"HR needs to understand what the CEO needs, where the organization is headed to better prepare itself," Drake says. "I know we talk about workforce shortages, but many of our hospitals haven't seen it yet and if they aren't paying attention. Five years down the road they are going to hit a wall where they don't have enough nurses or physicians. People will be retiring at an astronomical rate and maybe HR hasn't done enough to prepare or even to understand that this is coming down the pike."
Perhaps the biggest single impetus for expanding the strategic role of healthcare HR will come from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which attaches cold, hard cash to the once-fuzzy term "patient satisfaction."
"HCAHPS will go a long way in changing attitudes," says Michael DiPietro, with HealthcareSource, which has created a brief survey for ASHHRA that address the strategic role of healthcare HR. "Now there is transparency. Now there is so much more focus on patient satisfaction and quality outcomes. Patient satisfaction is directly impacted by the competencies and behaviors of employees. That is a key driver. As CEOs get more pressure to improve HCAHPS scores, there are certain things you can do on the clinical side, but they are going to turn to the VP of HR and say 'you need to help solve this.'"
The ASHHRA survey asks healthcare HR executives what they're doing in three strategic areas -- patient safety, patient satisfaction, cost containment -- and what technologies they're using to support initiatives in these areas.
"We are always trying to figure out what is the connection between talent management or the role of HR as it links to quality and patient safety, and where we fall in," Drake says. "We have a variety of groups working in hospitals and in the pursuit of excellent and quality and patient safety roles, but we struggle as a professional society to figure out where we fit in. This study will help us find more linkages."
If you've got a few minutes, take the survey. It provides an opportunity to assess where you are as an HR executive, and what your strategic role will be for your healthcare organization. You'd better prepare, because HR is going strategic, with or without you.
A critical shortage of drugs, especially chemotherapy and pain relief medications, is endangering patient safety and costing hospitals an estimated $200 million per year as they scramble to procure substitutes, often at higher prices.
Now Sen. Herb Kohl (D-WI) wants the Federal Trade Commission to examine the impact that consolidation in the pharmaceutical industry may be having on the nation's drug supply.
Kohl said in a letter to FTC Chairman Jonathan Leibowitz that he was prompted to make the request after fielding numerous complaints from healthcare providers about widespread drugs shortages. Kohl is chairman of the Subcommittee on Antitrust, Competition Policy and Consumer Rights, which oversees the FTC.
"As you know, pharmaceutical industry consolidation in recent years has left fewer manufacturers for both branded and generic drugs," Kohl said in his letter. "There have been at least nine major pharmaceutical mergers since 2000, most of them valued at over $40 billion each. Just two years ago, in 2009, for example, there were three major mergers – the $68 billion Pfizer/Wyeth merger, the $ 41 billion Merck/Schering Plough merger, and the $47 billion Roche/Genetech merger. And just a few weeks ago, two of the leading generic drug companies, Teva and Cephalon, announced their intention to merge, a transaction valued at $7.5 billion. The impact of this consolidation may be having a serious effect on the availability of prescription drugs."
Roslyne Schulman, director for Policy Development at the American Hospital Association, told HealthLeaders Media that healthcare providers have been dealing with drug shortages for years, but that the problem has grown considerably in the last year or so. "It's a huge and growing issue. As the Senator mentioned, the number of shortages is unprecedented and it's affecting the ability of hospitals to provide care. They sometimes don't find out about a shortage until they try to place an order and they're told there is a backlog, with no idea when the shortage will be resolved," she says.
Schulman says the biggest shortages are linked to "the old standby generic drugs, many of them are what are referred to as sterile injectable drugs." Those are the biggest issue with regard to shortages now. A couple of generic manufacturers have been working with this coalition. They have been part of the discussion, looking at potential solutions.
Karl Uhlendorf, the deputy vice president of the Pharmaceutical Research and Manufacturers of America, said in a statement that "myriad factors contribute to drug shortages, including natural disasters; shifts in clinical practices; wholesaler and pharmacy inventory practices; raw material shortages; changes in hospital and pharmacy contractual relationships with suppliers and wholesalers; adherence to distribution protocols mandated by the Food and Drug Administration; individual company decisions to discontinue specific medicines; manufacturing challenges and consolidations.
"Regardless of the cause, in order to provide patients with uninterrupted access to medicines it is important for all of us who provide life-saving medications to work collaboratively to minimize unexpected disruptions in the supply of vital medicines," Uhlendorf said.
Schulman said the AHA supports Senate bill (S.296), which would strengthen FDA oversight of the nation's drug supply. The bill requires drug manufacturers to notify FDA at least six months in advance of a planned discontinuation or interruption to the drug supply, with penalties in place for noncompliance; requires the FDA to post on its Web site information about drug shortages and to distribute that information to providers and patients' advocacy groups so they can plan ahead; and requires FDA to develop criteria to identify drugs that are vulnerable to shortages, and plan for ways to mitigate or prevent the shortage.
Government action, however, may not be enough.
"It's going to be a combination of industry actions, regulatory change, and some legislative change," Schulman says. "I don't think FDA has the authority it needs to mitigate these issues."
Kohl, who has served four terms in the Senate, announced this month that he will not seek re-election next year.
The average per capita cost of healthcare services covered by commercial insurance and Medicare grew 5.77% over the 12 months ending in March 2011, continuing a nearly year-long deceleration of cost growth, Standard & Poor's Healthcare Economic Indices show.
March's results represent the lowest cost growth in the six-year history of the measure, and reflect a deceleration in healthcare cost growth from the +6.17% in annual growth posted in February, and +6.31% in January 2011 for this index, S&P said.
Even with the deceleration, healthcare costs grew by more than double the 2.7% growth in overall inflation as measured by the Consumer Price Index for the same 12-month period ending in March, Bureau of Labor Statistics data show.
In its six-year history, the highest annual growth rate for the S&P Composite index was during the 12-months ending May 2010, when it posted +8.74%. With March's report of +6.19%, claims costs growth rates have decelerated 2.97 percentage points in 10 months, S&P said.
A further breakdown shows that, over the 12 months ending March, healthcare costs covered by commercial insurance rose +7.57%, down from +7.97% for the 12-month period ending in February, as measured by the S&P Healthcare Economic Commercial Index. Medicare claim costs rose at an annual rate of +2.78%, for the 12-month period ending in March, down from of +3.22% for February, as measured by the S&P Healthcare Economic Medicare Index. This is also the lowest annual rate of growth posted for the Medicare Index in its six-year history, S&P said.
"If you look over the last year or so of data, it is apparent that the rates of increase in healthcare costs continue to slow down," David M. Blitzer, Chairman of the Index Committee at Standard & Poor's, said in the report. "While there was some volatility within months, the general trend has been a slowdown across all nine of the indices we publish. Most of the annual growth rates peaked in the late winter/early spring of 2010. Since then, most of these rates have fallen by 2 percentage points or more."
Blitzer said the biggest slowdown has been in the Hospital Medicare Index, where the annual growth rate fell from +8.30% in August 2009 to +1.18% in March 2011. "On the other hand, we have not seen an equal trend for the Hospital Commercial Index, where the annual growth rate peaked at +9.36% in May 2010, and is still reporting a healthy +8.36% as of March 2011," he said. "This phenomenon could be the possible result of two things: (1) costs for Medicare patients are being better contained than those covered under commercial insurance plans and (2) hospitals are using more procedures and services covered under commercial plans, contributing to the increase in total costs. We see a similar differential across the Professional Services Indices, but not as severe."
The S&P Healthcare Economic Indices estimate the per capita change in revenues accrued each month by hospital and professional services facilities for services provided to patients covered under traditional Medicare and commercial health insurance programs. The annual growth rates are determined by calculating a percent change of the 12-month moving averages of the monthly index levels versus the same month of the prior year, S&P said.
Community Health Systems Inc. said Wednesday it is fighting legal battles on several fronts that include subpoenas from two federal oversight agencies.
In a filing with the Securities and Exchange Commission, Franklin, TN-based CHS disclosed that it has been has been subpoenaed separately by the SEC, and the Department of Health and Human Services Office of Inspector General in Houston.
The SEC subpoena, dated May 13, requests "documents related to or requested in connection with the various inquiries, lawsuits, and investigations regarding, generally, emergency room admissions or observation practices at our hospitals," CHS CFO W. Larry Cash said in the SEC filing. "The subpoena also requests documents relied upon by the company in responding to the Tenet litigation, as well as other communications about the Tenet litigation."
The May 10 subpoena from HHS OIG calls for 71 patient medical records from a CHS hospital in Shelbyville, TN to be sent to the Assistant U.S. Attorney handling the OIG investigation of a CHS hospital in Laredo, TX. "We are unaware of any connection between these two facilities other than they are both affiliated with us. We will cooperate fully with the Department of Justice and the Office of the Inspector General in this investigation," Cash said in the SEC filing.
Also Wednesday, Cash said in the SEC filing that rival Tenet Healthcare Corp. -- until last week the subject of a hostile takeover attempt by CHS -- has filed an amended lawsuit in federal court in Dallas that "expands on the unverified facts set out in its prior complaint (filed April 11, 2011) and continues to assert that a mathematical difference between our observation visit rate and/or inpatient admission rate and industry averages is, in and of itself, fraudulent."
Cash said the refiled suit seeks an award of costs and disbursements that Tenet purportedly incurred in analyzing alleged false and/or misleading disclosures in CHS' proxy solicitations and related statements. "The suit arises out of the now withdrawn offers to acquire the common stock of Tenet and notification of an intention to nominate directors at Tenet's annual meeting of stockholders," Cash said in the filing. "We believe the allegations are without merit and will vigorously defend this suit."
Finally, Cash said in the SEC filing that CHS is a defendant in at least two shareholder lawsuits filed in federal court in Nashville. "Although we have not yet been served in either case, we are aware that two lawsuits have been filed, both in U.S. District Court for the Middle District of Tennessee. Norfolk County Retirement System v. Community Health Systems, Inc., Wayne T. Smith, and W. Larry Cash was filed on May 9. De Zheng v. Community Health Systems, Inc., Wayne T. Smith, and W. Larry Cash was filed on May 12," Cash said in the SEC filing.
"Both suits seek class certification on behalf of purchasers of our common stock between July 27, 2006 and April 11, 2011 and allege that misleading statements resulted in artificially inflated prices for our common stock. We believe these suits are without merit and will vigorously defend them."
In a somewhat related filing with the SEC earlier on Wednesday, CHS said that shareholders had overwhelmingly reelected three board members this week, including Cash, despite the call by one investor group to toss them out.
William Patterson, executive director of CtW Investment Group, in an April 21 letter to fellow shareholders, had called for the ouster of Cash, and board members James S. Ely III, and John A. Fry, "given their culpability for the growing scandal surrounding proper oversight of Medicare billing practices, which has precipitated a 25% decline in Community's market value."
Patterson was referring to Tenet's allegations in a lawsuit filed in April that CHS overbilled Medicare by as much as $377 million using medically unnecessary admissions that improved its bottom line and appeal to investors.
CHS abandoned its hostile takeover bid for Dallas-based Tenet earlier this month, after the Tenet board unanimously rejected what CHS called its "best and final offer" of $7.25 per share cash, or about $4.1 billion. Tenet CEO Trevor Fetter and Tenet board chair Edward A. Kangas said in a letter to Smith that the offer "grossly undervalues the company and is not in the best interests of Tenet or its shareholders."
Employers will see healthcare costs increase by 8.5% in 2012, up slightly from 2010, as the economy continues to rebound, according to the annual Behind the Numbers report on medical cost trends from the PwC Health Research Institute.
That financial hit could be "contained" to about 7%, however, with increased cost-shifting to employees, PwC Principal Michael Thompson told HealthLeaders Media.
"There are three levers that employers are looking at. One is certainly cost-sharing. It has been demonstrated that cost sharing does influence how people use services," Thompson says. "On the negative side, part of the reason they mandated that cost sharing be eliminated for preventative services was so that people would use preventative services.
"Secondly is education on how to use the system more effectively. Thirdly, there has been a dramatic and continued focus from employers on making employees much more conscious and accountable for their own health behaviors," he says.
Containing healthcare cost growth to 7% will likely puts it on a track that is more than double that of overall inflation as measured by the Consumer Price Index, which grew at 3.2% between April 2010 and April 2011.
Healthcare inflation has been slowed over the last two years by the weak economy, Thompson says, but as the economy recovers, costs are increasing too. "To some degree we have found that healthcare costs actually grow as a percentage of the economy during down cycles," Thompson says. "Interestingly though, this year we found more of a reaction than we typically find. That has been reflected in somewhat decreased levels of utilizations, more than we have seen in past recessions. We attribute some of that to the fact that there has been much more cost sharing in the plans than we've had in years. As a result, employees have experienced more of the cost of services during the downturn and consequently have used fewer services during the last year or so."
Based on interviews with health plans, PwC had projected a 9% increase in employer medical costs for recession-wracked 2010 and 2011. However, low utilization led to adjusted estimates in the medical cost trend to 7.5% for 2010 and 8% for 2011 before benefit plan changes.
The end of subsidized COBRA coverage in 2010 is offsetting otherwise rebounding utilization growth rates so far in 2011, but employers and health plans expect pent-up demand to put upward pressure on the medical cost trend to continue into 2012, the PwC report said.
"Employers in particular continue to be very concerned about healthcare costs that are growing at substantially higher than the economy or their businesses or their wages," Thompson told HealthLeaders Media. "As a result they are continuing to focus efforts to dampen the increases that they are seeing."
The PwC report includes survey data from 1,700 employers in 32 industries, and interviews with hospital executives, health plan actuaries, and other healthcare sector executives. The medical cost trend is the projected increase in the cost of medical services assumed in setting premiums for health insurance plans.
PwC identified three factors that will inflate the medical cost trend in 2012:
1.Consolidation among hospitals and physicians. This trend is expected to accelerate as health reform incentivizes hospitals and physicians to align and form Accountable Care Organizations. Health plans are concerned that consolidation will reduce competition among providers and drive up payment rates.
2.Increasing cost shifting from Medicare and Medicaid. In 2012, the increase in Medicare inpatient hospital rates is expected to be 3.3 percentage points below the expected growth in their costs. Hospitals and health plans agree that much of the difference shifts to private payers.
3.Post-recession stress on workers. Money, work, and the economy -- found by the American Psychological Association to be the top three causes of stress among the American workforce between 2007 and 2010 -- are taking a toll. Health plans and employers interviewed by PwC say they are beginning to see more claims for stress-induced illnesses, which are highly correlated to unhealthy behavior and adverse health conditions such as heart disease.
Several factors will deflate medical costs for health plans and employers in 2012 -- but not necessarily for consumers. These factors are:
More cost shifting. Employers are increasingly shifting the burden of rising medical costs to employees through higher cost sharing. High deductible plans were the fastest growing plan designs in 2011, according to PwC's Touchstone survey. Seventeen percent of employers surveyed said high deductible plans were their most common benefit design, up 4 percentage points from 2010. The PwC study also notes that healthcare reform could contribute to cost shifting by further discounting Medicare rates for inpatient care.
Blockbuster brand-name drugs going off patent. In 2012, the cumulative sales of drugs going off patent will be the largest in history, representing approximately $28.1 billion in pharmaceutical sales according to PwC estimates. Increased use of generics will moderate health spending growth.
Tiering on out-of-network providers. Employers are increasing deductibles, making it far less attractive for workers to use out-of-network physicians and hospitals. Forty-four percent of employers in 2011 compared to 29% of employers in 2010 said that their out-of-network deductible had crossed the $1,000 threshold. In some markets, payers are becoming more selective about which providers are in the network, choosing to exclude higher-cost and premier hospital systems.
Thompson says the federal health reform law will have minimal effect on the medical cost trend in 2012. Provisions of the Patient Protection and Affordable Care Act that took place prior to 2012 were small changes for which employers already have fully accounted. Medicaid expansions, health insurance exchanges, subsidies to buy private insurance, mandates for employers to offer insurance and mandates for individuals to buy insurance don't take place until 2014 or later.
HealthSouth Corp. announced Wednesday that it will sell its six long-term acute care hospitals to LifeCare Holdings, Inc. for approximately $120 million, in a deal that is expected to be completed by September.
"The sale of these six long-term acute care hospitals to LifeCare reinforces HealthSouth's strategic focus on its 97 core, inpatient rehabilitation hospitals," HealthSouth President/CEO Jay Grinney said in a media release.
Grinney said Birmingham, AL-based HealthSouth will use the money from the sale to "invest in the retirement of our 10.75% senior notes and our accelerated de novo strategy. Most importantly, this divestiture does not change the company's outlook for 2011: We still expect our 2011 full-year results will be at the high end of, or greater than, the Adjusted EBITDA range of $440 million to $450 million."
Based in Plano, TX, LifeCare operates 20 long-term acute care hospitals in nine states. In a media statement, LifeCare chairman and CEO Phillip B. Douglas said, "Our company’s primary focus is the operation of long-term acute care hospitals. We look forward to sharing best practices across all of our hospitals and continuing to advance care for medically complex patients who require intensive treatment over an extended period of time.”
Coker Group analyst Mark Reiboldt said in an e-mail to HealthLeaders: "This one is probably more straightforward and perhaps less strategic relative to broader market trends. I imagine HLS recognizes where reimbursement and costs are heading for long-term care and they would likely be better served to focus on their core strengths in PT, rehab and other ancillary services. I read this as an opportunity to divest these assets, retire debt, and refocus on the company's core profitability. "
HealthSouth will work with LifeCare to transition the hospitals' employees and ensure there will be no interruption to patient care during the transfer to the new ownership. "We want to recognize and thank our highly skilled employees at these hospitals for their years of service and wish them the best under LifeCare's leadership," Grinney said.
The hospitals in the sale include:
HealthSouth Hospital at Tenaya, Las Vegas, NV;
HealthSouth Hospital of Houston, Houston, TX;
HealthSouth RidgeLake Hospital, Sarasota, FL;
HealthSouth Hospital of Pittsburgh, Pittsburgh, PA;
HealthSouth Specialty Hospital of North Louisiana, Ruston, LA, and two satellite locations, HealthSouth Hospital of North Louisiana — Farmerville, LA, and HealthSouth Hospital of North Louisiana — Homer, LA.
These hospitals contributed $121.7 million of net operating revenues and $17.5 million of Adjusted EBITDA to HealthSouth Corporation in 2010. They will be treated as discontinued operations beginning in the second quarter of 2011, HealthSouth said.
HealthSouth, which specializes in inpatient rehabilitative healthcare services, operates in 26 states and in Puerto Rico, with a network of inpatient rehabilitation hospitals, long-term acute care hospitals, outpatient rehabilitation satellite clinics and home health agencies.
Shareholders at Community Health Systems this week ignored the urging of one investor group and overwhelming re-elected three members of the board of directors – including CFO W. Larry Cash – during the company's 2011 annual meeting.
William Patterson, executive director of CtW Investment Group, in an April 21 letter to fellow shareholders, had called for the ouster of Cash, and board members James S. Ely III, and John A. Fry, "given their culpability for the growing scandal surrounding proper oversight of Medicare billing practices, which has precipitated a 25% decline in Community's market value."
Patterson was referring to Tenet Healthcare Corp.'s lawsuit filed in April claiming that Franklin, TN-based CHS overbilled Medicare by as much as $377 million using medically unnecessary admissions that improved its bottom line and appeal to investors.
A CHS filing with the Securities and Exchange Commission, however, showed that Cash easily won re-election on Tuesday by garnering 90.4% of the votes. Ely and fry each received 82.9%.
The vote appeared to be a vindication for Cash, Ely, Fry, and CEO/President/Chairman Wayne T. Smith, who vigorously campaigned for their re-election. However, it was also clear that the CtW campaign made some shareholders leery. Two other board members who were not the subject of the CtW ouster campaign, William Norris Jennings, MD, and H. Mitchell Watson, Jr., were reelected with 99.5% and 98.4% of the vote, respectively, the SEC filing showed.
CHS abandoned its hostile takeover bid for Dallas-based Tenet earlier this month, after the Tenet board unanimously rejected what CHS called its "best and final offer" of $7.25 per share cash, or about $4.1 billion. Tenet CEO Travis Fetter and Tenet board chair Edward A. Kangas said in a letter to Smith that the offer "grossly undervalues the company and is not in the best interests of Tenet or its shareholders."
Audits of the federal agencies charged with implementing and monitoring security measures for healthcare information technology identified this week lax oversight and insufficient standards for healthcare providers.
The audits were conducted by the Department of Health and Human Services' Office of Inspector General, and targeted HIT security standards, privacy protection under HIPAA, and other security measures at the Centers for Medicare & Medicaid Services, and the Office of the National Coordinator. "These two reports are being issued simultaneously because OIG found weaknesses in the two HHS agencies entrusted with keeping sensitive patient records private and secure," OIG said in a media release.
The CMS audit, Nationwide Rollup Review of the Centers for Medicare & Medicaid Services Health Insurance Portability and Accountability Act of 1996 Oversight, examined seven hospitals across the country and found 151 "vulnerabilities" in systems and controls that are designed to safeguard electronic protected health information.
Those lapses included 124 "high impact vulnerabilities" such as unencrypted laptops and portable drives containing sensitive personal health information, outdated antivirus software and patches, unsecured networks, and the failure to detect rogue devices intruding on wireless networks, the OIG audit said.
"These vulnerabilities placed the confidentiality, integrity, and availability of ePHI at risk. Outsiders or employees at some hospitals could have accessed, and at one hospital did access, systems and beneficiaries' personal data and performed unauthorized acts without the hospitals' knowledge," the OIG audit said. "As a result, CMS had limited assurance that controls were in place and operating as intended to protect electronic protected health information, thereby leaving ePHI vulnerable to attack and compromise."
OIG called on HHS' Office of Civil Rights to continue a compliance review that began in 2009 to ensure that controls are in place to protect ePHI at covered entities.
OIG's Audit of Information Technology Security Included in Health Information Technology Standards examined ONC's mandate under the HITECH Act to develop HIT security as part of a national HIT interoperability infrastructure. The audit found "no HIT standards that included general information IT security controls … which provide the structure, policies, and procedures that apply to a healthcare provider's overall computer operations, ensure the proper operation of information systems, and create a secure environment for application systems and controls."
OIG said the findings on ONC, when combined with vulnerabilities found in earlier audits of hospitals, Medicare contractors, and state Medicaid agencies, "raise concern about the effectiveness of IT security for HIT if general IT security controls are not addressed."
ONC concurred with the audits recommendations that it:
Broaden its focus from interoperability specifications to also include well-developed general IT security controls for supporting systems, networks, and infrastructures;
Provide guidance to the health industry on established general IT security standards and IT industry security best practices;
Emphasize to the medical community the importance of general IT security;
Coordinate with CMS and HHS' Office for Civil Rights to add general IT security controls where applicable.
Aurora Health Care President/CEO Nick Turkal, MD, says the Milwaukee-based healthcare system will not take part in the federal government's Accountable Care Organization pilot projects unless significant changes are made to the proposed rules.
Turkal told HealthLeaders Media that the proposed rules issued last month by the Centers for Medicare & Medicaid Services create a program where risks outweigh rewards.
"We had been very excited about the concept of ACO and Aurora has been designed around the concept of accountable care. But the pilot as designed by CMS doesn't match with what we expected and I don't think it matches with what a lot of providers expected across the country," Turkal said.
The Aurora Health chief joins a growing chorus of healthcare providers who are raising concerns about key components of the proposed rules, and says he plans to send a letter to CMS before the end of the comment period, pointing out his concerns and providing a list of recommendations.
Turkal said he believes the concerns he has for the ACO proposed rules are widely shared by other healthcare providers, particularly the capitation schedule that puts ACOs at risk in the third year.
"If you look at the end game, what are we trying to accomplish with an ACO pilot? I think what we are asking is 'is the model that is out there now going to get us there?'" he explained. "We think the answer may be 'no,' that it is designed in a way that moves a little too quickly towards capitation for many markets, and that has a quite rigid approach to quality and efficiency."
"If you move too many markets too quickly to capitation, then you haven't allowed the time for adjustment for patients, for physicians, for hospitals, to make that move in a way that doesn't impair quality or service to patients, or become just a huge financial burden," he continued.
Turkal says the anti-monopoly provisions put forward by the Department of Justice also could prove to be overly burdensome for integrated care systems like Aurora. "There is a regulatory review by market and it is broadly defined. If you have more than 50% of any market you have to go through a regulatory process for approval of a pilot," he says. "In a case like ours, where we are an integrated delivery system, anything where we exceed 50% would mean a review in that market. For example, if we have the predominant home care agency in a rural market we immediately have to go through a regulatory hurdle, even though the pilot wouldn't necessarily change our market share at all because we may be the only provider. So, it created a regulatory hurdle that seems to be pretty complicated for those of us who span several different markets. In our case it would require regulatory reviews in virtually all our markets."
Chris Van Gorder, President and CEO, Scripps Health, said in an interview with HealthLeaders Media shortly after the proposed rules were released, "Frankly, I was surprised. I thought there would be more carrots, not so much stick." His reaction, and that of his peers at other hospitals and health systems is in this report.
Turkal also expressed widely held concerns about the retroactive assignment of patients to ACOs after the first year, and the potential problems with data sharing, including the right of patients to limit access to personal health data. "I'm not sure it gives us the flexibility to work with our patients in a way that will make it successful," he says.
Turkal says CMS' willingness to make fundamental changes to the proposed rules could determine whether or not the ACO model success.
"The fundamental issue is if CMS has proposed a model which is not going to work," he says. "After the June 6 [end to the] public comment period, are they fundamentally going to change the model or is it going to be just some minor adjustments around the edges? The real answer is that without some fundamental change in CMS' current proposed model, there are not going to be many takers."
"If you were interviewing people 10 years ago and now, the difference now is those of us in healthcare are ready for change and we want to make it work. But the end goal has to be around enhanced care at a lower cost," he says. "We don't believe this is designed in a way that is necessarily going to get people there in an effective way. As it stands now we would not participate. We are hopeful that CMS and DOJ as they receive comments will morph this into something more useable."
According to the HealthLeaders Media Industry Survey 2011, more than half, (52%) of physicians surveyed said they expect to be part of an ACO within the next five years. That survey, however, was completed months before the proposed rules were released in April.
In the past three years, the extent of on-the-job violence that healthcare workers face has received a lot of media attention and public sympathy. That attention has created pressure on political leaders to provide legal protections for the millions of professionals who dedicate their lives to healing.
Last week, Vermont became the latest state to take a more aggressive stance against healthcare workplace violence. The Associated Pressreports that a new law in the Green Mountain State bumps up a misdemeanor assault to a felony when the victim is a healthcare worker on the job, with penalties ranging from up to a year in prison for first-time offenders to up to 10 years for repeat offenders. New York and Massachusetts recently passed similar laws, and the Emergency Nurses Association (ENA) says that several other states are focusing on the problem.
Will these laws end healthcare workplace violence? No. But they do reflect an increasing public awareness of the extent of assaults against healthcare workers. And, where there is informed public awareness of an issue, usually there is progress.
Let's review the numbers. Bureau of Labor Statistics data for 2008—the latest figures available—show 2,890 work-related assaults at hospitals. Remember, this reflects only assaults that are serious enough to inflict injury and force the victim to miss at least one day of work. Other BLS data show that for every 10,000 hospital workers, there were eight workplace assaults that resulted in missed work days.
By comparison, in the overall private sector, there were only 1.7 workplace assaults resulting in missed work for every 10,000 workers. An ENA nationwide survey found that between 8% and 13% of ED nurses say they are victims of physical violence every week. More than half (54.8%) of the 3,211 nurses ENA surveyed at three-month intervals between May 2009 to February 2010 reported physical or verbal abuse at work in the week before taking the survey.
ENA President AnnMarie Papa, RN, says she's happy with the strengthened protections for healthcare workers, and she's hopeful that more states will enact ENA model legislation that makes penalties for assaults on healthcare workers the same as assaults on police officers and firefighters.
She's quick, however, to call for more proactive measures that identify security risks in hospitals and other healthcare facilities before the violence occurs, and training programs that allow for healthcare professionals to defuse potentially violent encounters. Many of the ENA suggestions can be found in its workplace violence prevention tool kit.
"Most importantly, you need to have an organizational buy-in," says Papa, who is also interim director of emergency nursing at The Hospital at the University of Pennsylvania, in Philadelphia. "Zero tolerance is probably the one single most important factor for nurses. When we see that we know our organization is standing with us. We know they are on the front line, maybe not physically, but they are there to help us deal with these issues."
Papa says more and more hospitals are also doing a better job supporting their employees who've been assaulted on the job, although she says much work in that area remains to be done.
"If someone gets hurt at work, they break their ankle or there is a chemical splash, they have workers comp and other support. But often violence is overlooked as a worker's compensation issue. They have to use their vacation time or sick time to take time off," Papa says.
Also, Papa recommends that hospital leaders personally reach out to employees who've been assaulted on the job to offer their support. "I work in a Level 1 urban hospital in Pennsylvania. Whenever one of our nurses is the victim of violence, someone in our C-Suite calls that nurse to ask 'How can I help you?' Nine out of 10 times that nurses is going to say 'I'm fine. Thanks for the call.' But I can tell you that they talk about the fact that they received that call. They feel very, very supported."
The victims of assault are often frightened, angry, and confused. Imagine the impact that senior leadership could have on employee moral if the C-Suite is there both to support proactive antiviolence programs, and to offer assistance when on-the-job assaults occur.
If you're trying to build employee engagement in your healthcare organization, you can start by ensuring that you're there to support your employees when they are most vulnerable. They'll remember.
