Acute Care for Elders units are based on the idea that if the unique needs of seniors are met, they will have better outcomes and their care will be less costly. Research has shown that the units reduce readmissions.
This article first appeared August 16, 2016 on the Kaiser Health News website
BIRMINGHAM, Ala. — Thelma Atkins ended up in the University of Alabama at Birmingham (UAB) Hospital-Highlands after a neighbor in her senior living center ran over her feet with a motorized scooter.
Terri Middlebrooks, a nurse at the hospital, tried to figure out how active the 92-year-old Atkins was before the incident. "Are you up and moving at home?" she asked.
"I can manage, but I have to have help sometimes," Atkins replied.
Atkins said she uses a walker to visit friends and to get to the communal dining room. But she's also fallen a few times in recent years.
"Don't quit walking here," Middlebrooks told her. "It's the most important thing you can do. … This bed is not your friend."
Middlebrooks is the coordinator of a unit designed to address the challenges specific to caring for the elderly. She told her new patient that throughout her stay, one of the main goals would be to keep her active.
The medical center's effort to get older patients up and moving while they are in the hospital is far from typical. Despite a growing body of research that shows staying in bed can be harmful to seniors, many hospitals still don't put a high priority on making them walk.
At UAB Hospital-Highlands' 26-bed geriatric unit, known as the Acute Care for Elders unit, or ACE, patients are encouraged to start moving as soon as they arrive. The unit is one of a few hundred around the U.S. that is attempting to provide better and more tailored care to geriatric patients.
The hospital opened the unit in 2008 with the recognition that the elderly population was growing and that many older patients didn't fare well in the hospital. ACE units are based on the idea that if the unique needs of seniors are met, they will have better outcomes and their care will be less costly.
Research has shown that the units shorten patients' stays in the hospital, reduce their likelihood of returning too soon after discharge and make it less likely they will be sent to a nursing home.
In addition to employing specially trained staff who work together as a team, the Alabama unit has special handrails attached to the walls, low-glare lighting and non-skid floors. Every room has a walker and plenty of space to move around. Volunteers walk with patients, and therapists work with them on maintaining their strength.
Staff members try to disabuse patients of the idea that they are there to rest. "People walk in the door of a hospital and think it's OK to stay in a bed. It's not," said Middlebrooks.
Andres Viles, a nurse coordinator, said nurses at other hospitals are often so busy administering medications and tending to wounds that they don't make time to walk with their charges. The emphasis on patient mobility is "a culture change" for most hospitals, he said.
At UAB Hospital-Highlands, that shift took a lot of education. Staff members in the new unit attended workshops that included role playing and sensitivity training. The hospital also trained "geriatric scholars," who became advocates for addressing the particular physical and cognitive needs of seniors.
The Affordable Care Act explains some of the reluctance by staff at many hospitals to get patients moving, experts say. Under the law, hospitals are penalized for preventable problems, including falls. Researchers believe that hospital staffers, to ensure their patients don't fall, often leave them in their beds.
"We are doing an awful lot to prevent falls, but there is a cost," said Heidi Wald, an associate professor at the University of Colorado School of Medicine. "The cost is decreased mobility."
Researchers said there are other explanations for the failure of hospitals to get elderly patients moving. They may not have enough staff, for example, or they may fear lawsuits.
Families won't sue if their mom gets weaker in the hospital, but they may if she falls, said Cynthia Brown, director of the Division of Gerontology, Geriatrics and Palliative Care at the UAB School of Medicine.
"Why would the hospital want to put themselves at risk for litigation or the CMS [Centers for Medicare and Medicaid Services] coming back and biting them?" she said.
Brown added that hospital staffers around the country generally do not consider walking with patients to be as important as their other duties. "It is just one more thing on a list of a whole lot of things," she said. "Often times, walking falls to the bottom."
It's also harder for patients to walk around if they are attached to IV lines or oxygen tanks, or if they take drugs that make them sleepy. Such medication or equipment is not always necessary.
The very layout of hospitals and the way they operate makes it too easy for patients to remain stationary. They can control their televisions by raising a finger, and they typically get their food in bed.
On average, hospitalized older patients spend just 43 minutes a day standing or walking, according to astudy by Brown published in the Journal of the American Geriatrics Society. They are in bed more than 80 percent of their hospital stay, she found.
The impact of remaining so sedentary in the hospital can be devastating for older patients: It is puts them at greater risk for blood clots, pressure ulcers and confusion.
Immobility can also reduce patients' ability to take care of themselves when they go home — a difficulty that persists a month after their discharge, according to Brown. And it puts them at higher risk of readmission to the hospital, according to research.
Immobility hurts older patients more than younger ones, in part because the elderly are generally weaker, have less bone density and are at higher risk of falling. Ironically, keeping a patient in bed, which is often intended to prevent falls in the hospital, can increase their risk of falling after they are discharged, experts said.
Instead of returning home to their normal lives, patients who can't walk when they leave the hospital are more likely to go into nursing homes, said Seth Landefeld, chairman of the Department of Medicine at the UAB School of Medicine.
"They don't bounce back," Landefeld said. "The pneumonia is better, but Aunt Mary is not walking and talking the same as before."
Landefeld said hospitals frequently take the "smart bomb" approach to illness. "We blow away the disease, but we leave a lot of collateral damage," he said.
Making sure hospitalized patients spend sufficient time out of their beds can save money, keep them mobile after they return home and improve their overall health. Researchers in Texas found that increasing the number of steps elderly patients took on their first and last days in the hospital reduced their risk of dying over the following two years. A study of pneumonia patients of all ages showed that walking early in their hospital stay shortened its duration, saving an average of $1,000 per patient.
The hospital hosts a twice-weekly session called "Move and Groove," designed to get older patients dancing. At a recent session, a music therapist played the piano as the patients held tambourines or bells and moved their feet to the beat. All of the patients used walkers. A few had oxygen tanks and most wore bracelets indicating they were at risk of falling.
Occupational therapist Linda Pilkerton said she doesn't give patients a choice of whether to participate.
"We don't ask them if they want to do an x-ray or if they want a CT scan," she said. "This is ordered by the doctor. If they don't get up and move, they start the death spiral."
After Atkins was admitted to the unit following the scooter mishap, Middlebrooks told her it would only take two days of lying in bed to lose muscle mass. "And if you lose muscle mass, you get weaker and you're more apt to fall," the nurse explained, adding that Atkins had done enough of that.
Atkins, who has a pacemaker and has had hip and hernia surgeries, said she has lived alone a long time and doesn't want to end up in a nursing home. As she pushed her walker down the hospital corridor, she acknowledged that she's gotten weaker as she's gotten older and that her arthritis makes it more difficult to shower and dress by herself.
But she said she's determined to keep walking — at home and in the hospital.
"I don't want to lose more independence," she said. "I've already lost a lot of it."
But even if patients spend a lot of time out of bed while they are in the hospital, it does not guarantee they will recover.
Willie Mae Rich, 86, came to the Alabama hospital this spring because her doctor was concerned about her heart. Rich knew her bones wouldn't withstand a fall, so she worried about walking around too much.
"I'll break up like peppermint candy," she said.
But the hospital staff didn't give her a choice. They urged her to eat meals while sitting in a chair, get herself dressed and get up as often as possible.
"The more time you spend out of this bed, the healthier you'll be," Viles told her.
Despite staying active in the hospital, Rich, a great-grandmother, became more sedentary over the next several weeks. Her daughter, Debra Rich-Horn, said her mother continued to walk when she first came home, but soon she could barely get out of bed.
In May, she passed away.
"Her heart was already at a bad stage," Rich-Horn said. "By the time [the hospital] got her, it was too late."
States are beginning to require doctors to take continuing medical education courses that detail how marijuana interacts with the nervous system and other medications, as well as its side effects.
This article first appeared August 15, 2016 on the Kaiser Health News website
Medical marijuana has been legal in Maine for almost 20 years. But Farmington physician Jean Antonucci says she continues to feel unprepared when counseling sick patients about whether the drug could benefit them.
Will it help my glaucoma? Or my chronic pain? My chemotherapy's making me nauseous, and nothing's helped. Is cannabis the solution? Patients hope Antonucci, 62, can answer those questions. But she said she is still "completely in the dark."
Antonucci doesn't know whether marijuana is the right way to treat an ailment, what amount is an appropriate dose, or whether a patient should smoke it, eat it, rub it through an oil or vaporize it. Like most doctors, she was never trained to have these discussions. And, because the topic still is not usually covered in medical school, seasoned doctors, as well as younger ones, often consider themselves ill-equipped.
Even though she tries to keep up with the scientific literature, Antonucci said, "it's very difficult to support patients but not know what you're saying."
As the number of states allowing medical marijuana grows — the total has reached 25 plus the District of Columbia — some are working to address this knowledge gap with physician training programs. States are beginning to require doctors to take continuing medical education courses that detail how marijuana interacts with the nervous system and other medications, as well as its side effects.
Though laws vary, they have common themes. They usually set up a process by which states establish marijuana dispensaries, where patients with qualifying medical conditions can obtain the drug. The conditions are specified on a state-approved list. And the role of doctors is often to certify that patients have one of those ailments. But many say that, without knowing cannabis' health effects, even writing a certification makes them uncomfortable.
"We just don't know what we don't know. And that's a concern," said Wanda Filer, president of the American Academy of Family Physicians and a practicing doctor in Pennsylvania.
This medical uncertainty is complicated by confusion over how to navigate often contradictory laws. While states generally involve physicians in the process by which patients obtain marijuana, national drug policies have traditionally had a chilling effect on these conversations.
The Federation of State Medical Boards has tried to add clarity. In an Aug. 9 JAMA editorial, leaders noted that federal law technically prohibits prescribing marijuana, and tasks states that allow it for medical use to "implement strong and effective … enforcement systems to address any threat those laws could pose to public safety, public health, and other interests." If state regulation is deemed insufficient, the federal government can step in.
That's why many doctors say they feel caught in the middle, not completely sure of where the line is now drawn between legal medical practice and what could get them in trouble.
In New York, which legalized marijuana for medicinal purposes in 2014, the state health department rolled out a certification program last October. (The state's medical marijuana program itself launched in January 2016.) The course, which lasts about four hours and costs $249, is part of a larger physician registration process. So far, the state estimates 656 physicians have completed the required steps. Other states have contacted New York's Department of Health to learn how the training works.
Pennsylvania and Ohio are also developing similar programs. Meanwhile in Massachusetts, doctors who wish to participate in the state medical marijuana program are required to take courses approved by the American Medical Association. Maryland doesn't require training but encourages it through its Medical Cannabis Commission website, a policy also followed in some other states.
Physicians appear to welcome such direction. A 2013 study in Colorado, for instance, found more than 80 percent of family doctors thought physicians needed medical training before recommending marijuana.
But some advocates worry that doctors may find these requirements onerous and opt out, which would in turn thwart patients' access to the now-legal therapy, said Ellen Smith, a board member of the U.S. Pain Foundation, which favors expanded access to medical cannabis.
"It's very difficult to support patients but not know what you're saying."
Education is essential, given the complexity of how marijuana interacts with the body and how little physicians know, said Stephen Corn, an associate professor of anesthesiology, perioperative and pain medicine at Harvard Medical School. Corn also co-founded The Answer Page, a medical information website that provides educational content to the New York program, as well as a similar Florida initiative. The company, one of a few groups to offer teachings on medical marijuana, is also bidding to supply information for the Pennsylvania program, Corn said.
"You need a multi-hour course to learn where the medical cannabis works within the body," Corn said. "As a patient, would you want a doctor blindly recommending something without knowing how it's going to interact with your other medications? What to expect from it? What not to expect?"
But many say the science is too weak to answer these questions.
One reason: the federal Drug Enforcement Agency classifies marijuana as a schedule I drug, the same level as heroin. This classification makes it more difficult for researchers to gain access to the drug and to gain approval for human subjects to participate in studies. The White House rejected a petition this past week to reclassify the drug in a less strict category, though federal authorities say they will start letting more facilities grow marijuana for the purpose of research. (Currently, only the University of Mississippi can produce it, which advocates say limits study.)
From a medical standpoint, the lack of information is troubling, Filer said.
"Typically, when we're going to prescribe something, you've got data that shows safety and efficacy," she said. With marijuana, the body of research doesn't match what many doctors are used to for prescription drugs.
Still, Corn said, doctors appear pleased with the state training sessions. More than 80 percent of New York doctors who have taken his course said they changed their practice in response to what they learned.
But even now, whenever Corn speaks with doctors about medical marijuana, people ask him how they can learn more about the drug's medical properties and about legal risks. Those two concerns, he said, likely reduce the number of doctors comfortable with and willing to discuss marijuana's place in medicine, even if it's allowed in their states.
Though others say this circumstance is starting to ease, doctors like Jean Antonucci in Maine continue to struggle to figure out how marijuana can fit into safe and compassionate medicine. "You just try and be careful — and learn as much as you can about a patient, and try to do no harm," she said.
About one-third of patients over 70 years old and more than half of patients over 85 leave the hospital more disabled than when they arrived, research shows.
This article first appeared August 9, 2016 on the Kaiser Health News website
SAN FRANCISCO — Janet Prochazka was active and outspoken, living by herself and working as a special education tutor. Then, in March, a bad fall landed her in the hospital.
Doctors cared for her wounds and treated her pneumonia. But Prochazka, 75, didn't sleep or eat well at Zuckerberg San Francisco General Hospital and Trauma Center. She became confused and agitated and ultimately contracted a serious stomach infection. After more than three weeks in the hospital and three more in a rehabilitation facility, she emerged far weaker than before, shaky and unable to think clearly.
She had to stop working and wasn't able to drive for months. And now, she's considering a move to Maine to be closer to relatives for support.
"It's a big, big change," said her stepdaughter, Kitty Gilbert, soon after Prochazka returned home. "I am hopeful that she will regain a lot of what she lost, but I am not sure."
Many elderly patients like Prochazka deteriorate mentally or physically in the hospital, even if they recover from the original illness or injury that brought them there. About one-third of patients over 70 years old and more than half of patients over 85 leave the hospital more disabled than when they arrived, research shows.
As a result, many seniors are unable to care for themselves after discharge and need assistance with daily activities such as bathing, dressing or even walking.
"The older you are, the worse the hospital is for you," said Ken Covinsky, a physician and researcher at the University of California, San Francisco division of geriatrics. "A lot of the stuff we do in medicine does more harm than good. And sometimes with the care of older people, less is more."
Hospital staff often fail to feed older patients properly, get them out of bed enough or control their pain adequately. Providers frequently restrict their movements by tethering them to beds with oxygen tanks and IV poles. Doctors subject them to unnecessary procedures and prescribe redundant or potentially harmful medications. And caregivers deprive them of sleep by placing them in noisy wards or checking vital signs at all hours of the night.
Interrupted sleep, unappetizing food and days in bed may be merely annoying for younger patients, but they can cause lasting damage to older ones. Elderly patients are far different than their younger counterparts — so much so that some hospitals are treating some of them in separate medical units.
San Francisco General is one of them. Its Acute Care for Elders (ACE) ward, which opened in 2007, has special accommodations and a team of providers to address the unique needs of older patients. They focus less on the original diagnosis and more on how to get patients back home, living as independently as possible.
Early on, the staff tests patients' memories and assesses how well they can walk and care for themselves at home. Then they give patients practice doing things for themselves as much as possible throughout their stay. They remove catheters and IVs, and encourage patients to get out of bed and eat in a communal dining area.
"Bed rest is really, really bad," said the medical director of the ACE unit, Edgar Pierluissi. "It sets off an explosive chain of events that are very detrimental to people's health."
Such units are still rare — there are only about 200 around the country. And even where they exist, not every senior is admitted, in part because space is limited.
Prochazka said the constant checks by hospital staff made it hard for her to get a good night's sleep during her stay in the hospital. The night before, she said, she pulled the covers over her head in order to be left alone. (Heidi de Marco/KHN)
Prochazka went to the emergency room first, then intensive care. She was transferred to ACE about a week later. The staff weaned her off some of her medications and got her up and walking. They also limited the disorienting nighttime checks. Prochazka said she got "the first good night of sleep I have had."
But for her, the move might have been too late.
"She will not leave here where she started," Pierluissi said several days before Prochazka was discharged. "She is going to be weaker and unable to do the things you really need to do to live independently."
Not A Priority
How hospitals handle the old — and very old — is a pressing problem. Elderly patients are a growing clientele for hospitals, a trend that will only accelerate as baby boomers age. Patients over 65 already make up more than one-third of all discharges, according to the federal government, and nearly 13 million seniors are hospitalized each year. And they stay longer than younger patients.
Many seniors are already suspended precariously between independent living and reliance on others. They are weakened by multiple chronic diseases and medications.
One bad hospitalization can tip them over the edge, and they may never recover, said Melissa Mattison, chief of the hospital medicine unit at Massachusetts General Hospital.
"It is like putting Humpty Dumpty back together again," said Mattison, who wrote a 2013 report detailing the risks elderly patients face in the hospital.
Yet the unique needs of older patients are not a priority for most hospitals, Covinsky said. Doctors and other hospital staff focus so intensely on treating injuries or acute illnesses — like pneumonia or an exacerbation of heart disease — that they can overlook nearly all other aspects of caring for the patients, he noted.
In addition, hospitals face few consequences if elderly patients become more impaired or less functional during their stays. The federal government penalizes hospitals when patients fall, get preventable infections or return to the hospital within 30 days of their discharge. But hospitals aren't held accountable if patients lose their memories or their ability to walk. As a result, most don't measure those things.
"If you don't measure it, you can't fix it," Covinsky said.
Improving care for older patients requires an investment that hospital administrators are not always willing to make, experts said. Some argue, however, that the investment pays off — not just for older people but for hospitals themselves as well as for a country intent on controlling health care spending.
Though research on the financial impact of problematic hospital care for the elderly has been limited, a 2010 report by the Department of Health and Human Services' Office of Inspector General found that more than a quarter of hospitalized Medicare beneficiaries had suffered an "adverse event," or harm as a result of medical care.
Those events, such as bed sores or oxygen deficiency, cost Medicare about $4.4 billion annually, according to the report. Physicians who reviewed the incidents determined that 44 percent could have been prevented.
In addition to outright mistakes, poor or inadequate treatment in hospitals leads to needless medical spending on extended hospital visits, readmissions, in-home caregivers and nursing home care. Nursing home stays cost about $85,000 a year. And the average hospital stay for an elderly person is $12,000, according to the Agency for Healthcare Research and Quality.
"If you don't feed a patient, if you don't mobilize a patient, you have just made it far more likely they will go to a skilled nursing [facility], and that's expensive," said Robert Palmer, director of the geriatrics and gerontology center at Eastern Virginia Medical School and one of the brains behind the idea of ACE units.
ACE units have been shown to reduce hospital-inflicted disabilities in older patients, decrease lengths of stay and reduce the number of patients discharged to nursing homes. In one 2012 Health Affairs study, Palmer and other researchers found that hospital units for the elderly saved about $1,000 per patient visit.
A Different Life
After coming home, Prochazka said she felt weak. It took weeks of walking her labradoodle, Gino, to regain strength.
Her stepdaughter, Gilbert, said Prochazka has started to improve. "We knew she was getting better when she was getting ornery," she said.
But Prochazka, who is highly educated, still has some short-term memory loss, Gilbert said.
Prochazka knows that her life after hospitalization is different than before — she will have to depend more on others. It's not an easy adjustment, she said.
"I have been somebody who has always been both mentally and physically active," she said. "Before I fell … I was respected for what I have and what I did and all of a sudden, I'm not."
She said her time at San Francisco General was frustrating. Getting the infection just as she was starting to recover was especially hard, she said. "I felt like I had been dealt a blow I really didn't need."
For other patients, being admitted proactively to the special geriatric unit can stave off such precipitous declines.
Rosenda Esquivel, 80, spent 18 days at San Francisco General, much of it in the unit, this spring. She suffered no noticeable setbacks, physical or mental, during her time in the hospital, according to Annelie Nilsson, a clinical nurse specialist in the unit.
Esquivel, an animated woman who used to work as a home caregiver, was admitted with intense arthritic pain and, while hospitalized, underwent a procedure to address an abnormal heartbeat.
Soon after her arrival, Pierluissi, the ACE unit medical director, speaking to Esquivel in her native Spanish, sought to determine how independent she was at home. He learned that a friend helped take care of her but that she took pride in cooking and cleaning for herself.
The doctor noticed that Esquivel needed help to get up from a chair but that she could get around with a walker. Her memory, though, wasn't too strong. A few minutes after hearing three words — "honesty," "baseball" and "flower" — she could only recall one of them.
Pierluissi came up with a plan for her time in the hospital: Get Esquivel's pain under control. Make sure she walks three or four times a day. Arrange for her to have a caregiver at home to remind her to take her diabetes and blood pressure medications.
Then, release her as fast as possible.
"The less time she spends here, the better," Pierluissi said.
The California Hospital Association and the California Medical Association, which represents doctors, agree that nurse-midwives have the training and qualifications to practice without physician supervision. But they differ sharply over whether hospitals should be able to employ midwives directly.
This article first appeared August 8, 2016 on the Kaiser Health News website
By Anna Gorman
A California bill that would allow certified nurse-midwives to practice independently is pitting the state's doctors against its hospitals, even though both sides support the main goal of the legislation.
The California Hospital Association and the California Medical Association, which represents doctors, agree that nurse-midwives have the training and qualifications to practice without physician supervision.
But they differ sharply over whether hospitals should be able to employ midwives directly — a dispute the certified nurse-midwives fear could derail the proposed law.
"We are very much caught in the middle," said Linda Walsh, president of the California Nurse-Midwives Association.
The bill would override an existing law that requires certified nurse-midwives to practice under the supervision of medical doctors. California is one of only six states that requires full supervision. Several other states mandate other forms of collaboration, such as in prescribing medications.
The American College of Nurse-Midwives has been chipping away for decades at state laws that require physician supervision, and it has finally passed the tipping point nationally, said Jesse Bushman, director of federal government affairs for the organization. Nurse-midwives aren't seeking permission to go off and do whatever they want without consulting anyone, Bushman said. "They're just asking to be able to do what they are trained to do."
In states where nurse-midwives can practice independently, there is more access to care, he said, citing a recent report published by the George Washington University's Jacobs Institute of Women's Health.
There are more than 11,200 nurse-midwives around the nation, including about 1,200 in California. They provide maternity care, family planning services and other primary care for women.
In 2013, California eliminated the physician supervision requirement for licensed midwives, who require significantly less training than nurse-midwives. Unlike licensed midwives, certified nurse-midwives must become registered nurses and obtain a graduate degree in midwifery. They primarily deliver babies in hospitals, while licensed midwives usually work in homes or birth centers.
Walsh said her association is trying to make it easier for certified nurse-midwives to practice around the state, especially in areas where there may not be any obstetricians. It can be challenging to find physicians willing to oversee nurse-midwives, because of the responsibility and liability involved, she said.
"We have an access issue in California," Walsh said. "Yet we have this supervisory language that prevents an increase in access for the people who need it most."
Lisa Catterall, who works in a hospital-based midwifery practice at Feather River Hospital in Paradise, Calif., said getting physician supervision is not easy. For one thing, some nurse-midwives have to pay extra malpractice insurance in addition to paying doctors for their supervision. Even with the supervision, the doctors are not required to be present to oversee the care, added Catterall, who delivers about 100 babies a year and sees patients from throughout the rural region north of Sacramento where her hospital is located.
The debate between the doctors and the hospitals centers on the state's prohibition of what's known as the "corporate practice of medicine." California does not allow corporations, including hospitals, to hire physicians, though there are several exceptions. The intent of the ban is to avoid undue corporate influence on doctors' medical judgment and patient care. Under current law, hospitals can hire nurse-midwives, though many don't.
One of the bill's co-authors, Assemblywoman Autumn Burke, recently withdrew an amendment that would have mirrored the law applying to doctors by barring hospitals from hiring nurse-midwives. With that provision withdrawn, the California Medical Association now opposes the legislation and the California Hospital Association supports it.
The physicians' group believes that the health care decisions of nurse-midwives employed directly by hospitals could be influenced by their administrators, and it says it will only back the bill if the amendment is reinstated.
Patients should have the same consumer protections whether they see a nurse-midwife or a doctor, said Juan Thomas, a lobbyist with the medical association. "It should be a level playing field," he said. "We believe very strongly that the corporate practice of medicine bar language provides an important layer of patient protection."
The California Hospital Association, meanwhile, won't support the bill if the amendment is reinstated. The association believes hospitals need to retain the freedom to hire nurse-midwives.
A ban on hiring would make it more difficult for nurse-midwives to work in hospitals, forcing them into roundabout contracts that are "unduly cumbersome, unduly burdensome and unnecessary," said Jackie Garman, a vice president of the hospital association.
In addition, Garman said, some nurse-midwives are already employed by hospitals. "What happens to them?" she asked.
The nonprofit Pacific Business Group on Health recently announced its support of the midwife bill, saying it would help expand women's choices in pregnancy care and lead to better maternal health. In the spring, the group had sponsored a roundtable with more than 30 organizations from around California to discuss increasing access to nurse-midwives.
"It is really hard to argue with the evidence about the value that midwives offer pregnant women," said Brynn Rubinstein, the group's senior manager for transforming maternity care. "They are delivering more patient-friendly care, yielding better outcomes and saving money for purchasers," she said. "But they are not always easy to find."
Research shows that patients of certified nurse-midwives have fewer cesarean deliveries and lower epidural rates.
Assemblywoman Burke's office is continuing to talk to representatives of both the physicians and the hospitals to try and find a solution to the contentious issue of whether hospitals should be allowed to hire nurse-midwives, said Allison Ruff, a senior aide to Burke.
"For both of them, it is an issue they don't want to compromise on," she said. "The bill became a pawn in the fight between the hospitals and the physicians. It still is."
Private not-for-profit hospitals were the facilities most likely to offer language services. Yet, in areas with the greatest need, about 36% did not have systems in place. In areas with low need, seven out of ten facilities had the capability.
This article first appeared August 8, 2016 on the Kaiser Health News website
By Carmen Heredia Rodriguez
Luis Ascanio, 61, works as a medical interpreter at La Clinica del Pueblo, a D.C.-based clinic geared toward providing health care to the surrounding Latino community.
Fluent in Spanish and French, he helps doctors talk with patients with limited English skills about health care issues that range from highly technical to deeply emotional. "You are sort of a bridge," he said. "And it is very important that you do not obscure the context of the conversation."
But according to an analysis published Monday in Health Affairs, more than a third of the nation's hospitals in 2013 did not offer patients similar language assistance. In areas with the greatest need, about 25 percent of facilities failed to provide such services.
The researchers examined survey data collected from 4,514 hospitals nationwide by the American Hospital Association. In addition, they categorized the hospitals as to whether they offered language services and by their ownership status — private not-for-profit, private for-profit or government-owned. The researchers also calculated the number of residents with low English proficiency in the facilities' service areas using census data collected from 2009 to 2013.
They concluded that about 69 percent of hospitals offered language services. Hospitals serving areas with moderate needs provided proportionately more assistance than facilities located in low- or high-need areas.
"And I think we can do better," said Melody Schiaffino, lead author and associate professor in the Graduate School of Public Health at San Diego State University.
Private not-for-profit hospitals were the facilities most likely to offer language services. Yet, in areas with the greatest need, about 36 percent did not have systems in place. In areas with low need, seven out of ten facilities had the capability.
Government-owned and private for-profit hospitals were far less likely to provide such help. Less than a fifth of private facilities offered language aid. Government hospitals had similar rates.
Researchers found no pattern to explain which facilities provided language assistance. This inconsistency suggests patients go to hospitals that may be outside their official service area based on language services, Schiaffino said, resulting in higher costs for the facility and longer waiting periods for patients.
Further research is needed, the authors wrote, because immigration patterns are leading to new areas of language-diverse communities. Models need to be developed to predict where these pockets will emerge and what the level of need for assistance might become.
"A lot of hospitals probably are not aware of the change in diversity and the scale of diversity in their community as they think," said Schiaffino.
According to the study, 60 million people claim a primary language other than English. Spanish speakers alone account for more than 10 percent of the American population in 2011, according to the Census Bureau.
Based on civil rights law, any hospital receiving federal funds must have language services available for its patients. However, many patients do not know their right to access language services, the study noted, which could become more challenging as private for-profit hospitals — the kind least likely to offer this kind of help — continue to grow in market share.
But the challenge also provides an opportunity for hospitals to empower their customers to be informed patients.
"To receive a diagnosis in the language that you prefer is not an unreasonable request," Schiaffino said.
On Monday, Dr. Tom Frieden, head of the Centers for Disease Control and Prevention, recommended Zika testing for all pregnant women who have traveled since June 15 to the one-square-mile zone near Miami where mosquitoes have likely spread the virus locally.
This article first appeared August 5, 2016 on the Kaiser Health News website
By Sammy Mack
Late last fall, Dr. Christine Curry was at a faculty meeting with her colleagues when the conversation turned to new reports linking the Zika virus to a surge in microcephaly in infants in Brazil.
"I think it's fair to say that most obstetricians had never heard of this virus a year ago," said Curry, who is an assistant professor of obstetrics and gynecology at the University of Miami Miller School of Medicine and Jackson Memorial Hospital.
Curry, an obstetrician with a background in virology, volunteered to look into it for the rest of the staff.
"I knew from the get-go that it may end up being nothing, and just an interesting story out of Brazil, or it may end up being a reproductive game-changer — which is, I think, where we're at right now," Curry said.
Since raising her hand at that meeting, Curry estimates her practice has seen about half of the 55 pregnant Floridians who have screened positive for Zika infection. For Curry and her colleagues, discussing Zika risks with patients has become a standard part of prenatal care.
So far, all of Florida's Zika cases in pregnant women have been related to travel outside the continental United States. And for months, screening guidelines have suggested testing pregnant women who have traveled to Zika-affected areas, even if they don't have symptoms of infection. But now that there are at least 15 cases of locally-acquired Zika identified in South Florida, preventing and identifying infection in pregnant women is increasingly urgent.
On Monday, Dr. Tom Frieden, head of the Centers for Disease Control and Prevention, recommended Zika testing for all pregnant women who have traveled since June 15 to the one-square-mile zone in Wynwood and Midtown where mosquitoes have likely spread the virus locally.
Zika exposure in pregnancy has been linked to microcephaly and other abnormalities, but it's still unknown how often those problems develop in the babies of women who are exposed to Zika while pregnant.
"What we know about Zika is scary," said Frieden during a news conference Monday, adding that this is the first time a mosquito bite has been known to lead to a birth defect.
"But in some ways what we don't know about Zika is even more unsettling," he said. "We don't know the long-term impact Zika may have on children born to infected mothers who don't have obvious signs of microcephaly, and these effects may only become apparent months or years in the future."
Getting Tested
When Curry finds that a patient of hers has been to a place where there is active Zika transmission, she talks to her about getting a test — usually a blood test — that will determine whether she has the Zika antibodies or active virus in her system.
Those blood samples get sent to a state lab for testing. Curry said she's been getting results back within one to three weeks.
And while pregnant women tend to be prepared for the anxious waiting periods that come with all sorts of routine testing for birth defects during pregnancy, nothing has quite the profile of Zika right now.
"I got a mosquito bite this morning and it's probably the first time I ever cried over a mosquito bite," said Zonnia Knight, who is due with her second child in mid-October.
Knight lives in Palmetto Bay and works at a communications firm in Coral Gables, but she's spent time in Wynwood — including a dinner the night before pregnant women were told to avoid the area.
Knight called her midwife, who is giving her a prescription for a blood test that looks for antibodies that indicate whether or not she's had a Zika infection.
Knight's co-worker, Susie Gilden, is in her second trimester and is also asking for a Zika test because she's visited Wynwood since June 15. Until now, Gilden and her doctor in Hollywood haven't really talked about the virus.
"It would be nice to have some proactive communication to tell me what I should be doing," said Gilden, who said she's been "stalking" the CDC website and reading up on Zika online.
Positive For Zika
If a test in a pregnant woman does come back positive for having had Zika, her obstetrician has to add another layer of counseling and monitoring to her prenatal care.
"As with any time you deliver bad news, they're really upset and they don't hear everything you have to say initially," said Curry, who arranges to disclose the results of Zika tests with her patients in person, rather than over the phone.
There's a lot of conversation about next steps and, depending on the trimester, the mother's option to terminate the pregnancy. Curry said it's helpful to have a family member present.
"Or you may say, 'listen, I'm going to write this down for you. I'm going to see you again next week. And we're going to rehash this entire conversation when you've had a little bit of time to process things.'"
The mother may need to be retested for Zika antibodies. And her doctors will pay special attention to subsequent ultrasounds for abnormal head growth or calcifications in the baby's brain.
"You see these little calcifications in the brain that are really indicators that you're actually seeing loss of brain," said Dr. Aileen Marty, professor of Infectious Diseases in the Department of Medicine at Florida International University's Herbert Wertheim College of Medicine. She explained that the Zika virus appears to be attracted to stem cells that would otherwise become brain cells.
"And it basically tells the brain cell not to keep on maturing… It commits suicide and you lose those brain cells," Marty said.
Microcephaly is just one of the symptoms of a baby harmed by Zika. Marty and other researchers say it appears the virus is also associated with deformities of the hands and feet, trouble developing reflexes for sucking and swallowing, and vision and hearing loss.
Born With Zika Injuries
At the end of June, the Florida Department of Health announced the state's first birth of a child with Zika-related microcephaly. The baby's mother had gotten Zika outside the United States. The state said it would connect the family to Early Steps, a state- and federally-funded program that provides resources — like speech therapy and other developmental interventions — to children up to 3 years old who are at risk for developmental delays.
"Understand that this is going to be a chronic, lifelong problem," said Dr. Charles Bauer, a neonatologist and director of the Early Steps division in North Miami-Dade.
Bauer is part of a new team of doctors and therapists at UM and Jackson Health System who are coordinating to care for babies with Zika-related injuries. As soon as a baby with a known Zika exposure enters the nursery, Bauer and his colleagues will be able to start screening and developing a plan with the family.
"It's a brand new area. We don't know very much about it," Bauer said. "We could be looking at lots of other things that wouldn't show up until the baby is older and going to school — learning disabilities and things like that."
There are 15 Early Steps sites across Florida. Bauer's division sees around 3,500 infants and toddlers each year at a cost of about $7,500 per patient. The care is free to the family, though the program does bill insurance when possible.
Bauer said it's too soon to know how Zika will affect his caseload. But he said he is concerned that Washington has yet to agree on funding for Zika.
"They need to stop playing politics," he said. "It's a big problem and it's going to get bigger. As we know, it's escalating every day."
Against the backdrop of so much uncertainty, Bauer and other South Florida doctors are doing what they can to help expectant mothers and their babies.
"I picked Ob/Gyn because 95 percent of the time I am there for the happiest day of someone's life," Curry said. "But there's a small fraction of what we do that's really hard. It's the conversations about miscarriages and stillbirths and birth defects."
Curry is pragmatic. Even when she's delivering bad news, she sees opportunity to help a patient through the experience.
"It's about not losing the excitement of having a new baby, but also having a tempered expectation that we don't totally know what the infection may mean for the development of the baby," she said.
After a more than two-year moratorium on nearly all new adult patients, a California community health center has reopened its doors this month. The facility’s director discusses the experience of adjusting to the changes wrought by the Affordable Care Act.
This article first appeared August 3, 2016 on the Kaiser Health News website
A network of clinics that serves low-income patients in rural Northern California is finally finding balance after being deluged with newly insured patients under the Affordable Care Act.
After a more than two-year moratorium on nearly all new adult patients, the Redding-based Shasta Community Health Center has reopened its doors to some newcomers this month, and it will start accepting more new patients in September.
When Medi-Cal, California's version of Medicaid, was first expanded under the Affordable Care Act in early 2014, the number of people insured under the program doubled to around 40,000 people in the region served by Shasta Community Health. Not only did the clinics see new patients, but the demand for services soared from existing ones who were newly insured.
The clinic network already had a shortage of doctors and nurses. — a problem shared by many other rural health clinics in California.
"The … more new patients we brought in, the more stress on the providers, the more likely [they] were going to leave, the deeper the crisis went," said Shasta Community Health Center CEO C. Dean Germano. So he decided to close the network's five clinics to new adult Medi-Cal patients, though they continued to serve all of their existing patients and accepted new children.
During the moratorium, patients in the region had to travel long distances for primary care, or use the local emergency room, Germano said.
Shasta Community Health Center has since boosted its capacity to provide primary care. It has hired two physicians, created a family practice residency program and has a fellowship program for nurse practitioners and physician assistants. For every new primary care provider, the clinic network can add up to 1,200 new patients, Germano said. The system now serves about 60,000 people in the area.
California Healthline interviewed Germano about his health center's experience adjusting to the changes wrought by the Affordable Care Act. His comments have been edited for length and clarity.
Q: How did the ACA change the type of services you were giving or the type of care the patients needed?
Uninsured people tend to use the system much less and often at the worst possible places.
With the onset of coverage, you have all this relief to pent-up demand, people seeking more regular care and preventive [care], which often for the uninsured is not a priority. They tend to come in because they have acute issues or they have long-term chronic issues that have become complicated.
So [with] people gaining coverage, the uninsured are becoming much like our other insured populations — seeking care at the appropriate moments.
Q: Were you able to meet the demand for all these new services?
No, not at all. We quickly became overwhelmed, although there were a couple of things happening all at once. One was certainly the growth in Medicaid coverage, but at the very same time, the state of California expanded Medi-Cal managed care into 28 rural counties. We are one of them. We did not have Medi-Cal managed care prior to this.
We were assigned patients, then assigned more patients. We quickly reached a point where we could not take on more new adult patients to our practice. We had to essentially constrain and at one point close the practice to new adult Medicaid patients. We never closed the practice to uninsured patients because they don't have many options, as in the ER. We never close it to homeless or to children or to people with HIV. Interestingly enough, [it was] not a great business model because our best payers are the ones we closed to.
It was a very big hit [to] the community because adult patients had to go further afield to find services outside of the emergency room. Under managed care, it's [the health plan's] responsibility to find a medical home and some of the medical homes were 30 to 40 miles into the mountains. For patients who have transportation issues, there was no doubt that was a real imposition.
Q: Can you describe the region's shortage of providers?
We are close to 20 primary care physicians short in our community, including our insured and Medicare populations. In a rural community, that's a big number. So the deficit has always been there.
It's always been tough for rural areas to recruit [physicians], but in this environment where everyone is struggling to hire, it really made the challenge that much more difficult. Medical students don't go into primary care for lots of reasons. One of them is debt load. Most of the doctors I hire now usually have an average of $300,000 worth of student debt.
In addition, there are not enough family medicine residencies in California. We need a lot more primary care residencies, particularly in family medicine.
Q Do you think an increase in the rates Medi-Cal pays to providers is what's needed to ensure that all areas have the coverage they need?
The gap is so huge now between Medi-Cal and Medicare reimbursement. A five or ten percent adjustment would help the margins, but isn't going to create a wholesale shift of providers into Medi-Cal, because we're seeing in rural areas the provider shortage exists for patients covered by Medicare and private insurance.
Where we feel [the low reimbursements] the most is on the specialty care side. It's very difficult to get referrals in a timely way when the reimbursement is so pitifully poor. And we really lean on our specialty community.
When a specialist looks at a rural community, it's really hard for them to … say "I'm only going to take the insured patients," because typically there aren't enough insured patients to create a full practice. So they look at the full book of business. They look at what the insured population looks like, what the Medicare population looks like and then everybody else, particularly Medicaid. And in many specialties, particularly in pediatrics and the surgeries, you look at what percentage of your practice is going to be [covered by] Medicaid. In California, if that number is really high, it's often not viable for them to move into that rural community because that book of business doesn't make sense for them.
So, Medicaid being such a low payer has a huge ripple effect. And where that's important in rural communities is that if we don't have an EMT surgeon or a general surgeon or urologist because they can't put together a decent book of business, it's not just the poor people who suffer. It's the whole community.
Q: If increasing the Medi-Cal rates isn't necessarily the silver bullet, how would you remedy the overall problem of provider shortages in certain areas?
First of all, the reimbursement rate has to be better.
Secondly, we have not been good at developing training programs, particularly in the primary care specialties but across the board.
I wish there [were] money for post-graduate residency programs for [nurse practitioners and physician assistants] because if we don't have enough family doctors, general internists and pediatricians, then we're going to lean on our PAs and NPs.
Q: Would expanding the scope of what nurse practitioners can do help bring providers where they're needed?
Well, I have mixed feelings about that. If it's done in the context of a post-graduate residency program, I think that independence makes sense because they should've gotten a lot of what they needed to know. [But] just putting a new practitioner with an independent license out there and letting him hang his shingle out, I have mixed feelings about.
But I do think that if you can marry a post-graduate training program and a pathway for independence, that might work or maybe a certain number of years of practice under a physician's supervision.
The number of hospitals being penalized will be around the same as last year. But Medicare said the penalties are expected to total $528 million, about $108 million more than last year, because of changes in how readmissions are measured.
This article first appeared August 2, 2016 on the Kaiser Health News website
The federal government's penalties on hospitals will reach a new high as Medicare withholds more than half a billion dollars in payments over the next year, records released Tuesday show.
The government will punish more than half of the nation's hospitals — a total of 2,597 — having more patients than expected return within a month. While that is about the same number penalized last year, the average penalty will increase by a fifth, according to a Kaiser Health News analysis.
The new penalties, which take effect in October, are based on the rehospitalization rate for patients with six common conditions. Since the Hospital Readmissions Reduction Program began in October 2012, national readmission rates have dropped as many hospitals pay more attention to how patients fare after their release.
The penalties are the subject of a prolonged debate about whether the government should consider the special challenges faced by hospitals that treat large numbers of low-income people. Those patients can have more trouble recuperating, sometimes because they can't afford their medications or lack social support to follow physician instructions, such as reducing the amount of salt that heart failure patients consume. The Centers for Medicare & Medicaid Services says those hospitals should not be held to a different standard.
Medicare said the penalties are expected to total $528 million, about $108 million more than last year, because of changes in how readmissions are measured.
Medicare examined these conditions: heart attacks, heart failure, pneumonia, chronic lung disease, hip and knee replacements and — for the first time this year — coronary artery bypass graft surgery.
The fines are based on Medicare patients who left the hospital from July 2012 through June 2015. For each hospital, the government calculated how many readmissions it expected, given national rates and the health of each hospital's patients. Hospitals with more unplanned readmissions than expected will receive a reduction in each Medicare case reimbursement for the upcoming fiscal year that runs from Oct. 1 through September 2017.
The payment cuts apply to all Medicare patients, not just those with one of the six conditions Medicare measured. The maximum reduction for any hospital is 3 percent, and it does not affect special Medicare payments for hospitals that treat large numbers of low-income patients or train residents. Forty-nine hospitals received the maximum fine. The average penalty was 0.73 percent of each Medicare payment, up from 0.61 percent last year and higher than in any other year, according to the KHN analysis.
Under the Affordable Care Act, which created the penalties, a variety of hospitals are excluded, including those serving veterans, children and psychiatric patients. Maryland hospitals are exempted as well because Congress has given that state extra leeway in how it distributes Medicare money. Critical access hospitals, which Medicare also pays differently because they are the only hospitals in their areas, are also exempt.
As a result, more than 1,400 hospitals were automatically exempt from the penalties. Other hospitals did not have enough cases for Medicare to evaluate accurately and were not penalized. Of the hospitals that Medicare did evaluate, four out of five were penalized.
The KHN analysis found that 1,621 hospitals have been penalized in each of the five years of the program.
Researchers analyzed the effect of a web-based tool that uses patient medical records to enhance communication during the patient handoff. The number of medical mistakes was cut in half the year after the hospital introduced the software tool and taught employees how to use it.
This article first appeared August 1, 2016 on the Kaiser Health News website
It's 4 p.m., and if you're a hospital patient, that could be one of the most critical times of the day. Your doctor's shift just ended, and someone new will take over your care. How these professionals communicate could have major repercussions for your recovery.
Those shift changes, also known as handoffs, are prime opportunities for key information about a patient's condition to get lost in the shuffle. It's essential that these relevant points are not only captured, but also effectively conveyed between hospital staff.
All too often, that doesn't happen. But a research letter published Monday in JAMA Internal Medicine suggests hospitals can avoid such missteps by using technology to improve communication among the doctors, nurses and other health care providers at that vital point in care.
"This shows that [an electronic patient record] can help mitigate medical error," said Dr. Stephanie Mueller, the study's main author and an associate physician in primary care and general internal medicine at Brigham and Women's Hospital.
Researchers analyzed the effect of a web-based tool that uses patient medical records to enhance communication during the patient handoff. It scans a patient's electronic medical record for the information that doctors and other health workers need to know most. Then it automatically pulls that information into a separate page that's been designed to highlight those essential details.
To evaluate the tool, the researchers surveyed residents at the end of their shifts who worked "nightfloat" — midnight to 7 a.m. — and "twilight" — 4 p.m. to 12 a.m. They checked for possible medical errors, and then rated those errors in terms of how avoidable they were. The survey started in November 2012 in advance of the tool's February 2013 introduction, and then compared the level of error that took place before the tool was being used with those that occurred in the year that followed. Overall, the survey examined more than 5,000 patient cases.
The result: The number of medical mistakes was cut in half the year after the hospital introduced the software tool and taught employees how to use it. There were 77 errors identified between November 2012 and February 2013, compared with 45 in the following year.
As hospitals become more shift-driven because of increased attention to regulating physician work hours, these figures take on added importance. In the past, residents often worked 24-hour shifts. But safety advocates worried such a system could mean sleep-deprived doctors, who in turn would make more errors while treating patients. In fact, reducing hours has increased the number of patient handoffs, meaning there are more opportunities for information to get lost and for mistakes to be made.
The researchers argued their findings offer a path forward.
Brigham and Women's built its tool in-house and has integrated it into the hospital's commercially produced electronic health record.
This tool is unique to Brigham and Women's, but it offers a strategy that other hospitals and health facilities could adopt, said Robert Wachter, interim chair at the University of California San Francisco's Department of Medicine, and an expert in patient safety. Wachter co-authored a commentary published alongside the study.
"As hospital care is increasingly shift based, a clear and efficient handoff process is vital," according to the commentary. "[This] study … shows how web-based handoff tools may improve hospital workflow and patient safety, but only if they are carefully built and integrated into existing systems."
And that requires efforts by both the hospital and the vendors who develop and sell medical records systems to health facilities.
"This can be used as a model for what other health care institutions can do. … It gives a really good argument for what can be done," said Raj Ratwani, who researches health care safety and is the scientific director for MedStar Health's National Center for Human Factors in Healthcare in Washington, D.C. He was not involved in the study.
That said, any reduction in medical errors that resulted after the web-based handoff tool was put to use should not be viewed in isolation. Brigham and Women's also introduced an educational component that accompanied the technology's introduction. It emphasized how health professionals should talk to each other, to make sure the computer-based information is actually conveyed, and it focused on how to navigate the computer system. Plus, Mueller noted, health care is moving culturally toward emphasizing better communication, especially at shift changes. Those all could have had an impact, too.
But those threads are more entwined than they may appear, she said. Any hospital that turns to technology needs to properly teach staff how to use it and highlight why it's important.
"They're all merged," she said. "You're not going to throw a tool in someone's lap and say, 'Here. Use this, and good luck.'"
When it comes to hospitals, which benefit most from high health care prices? It may sound counter-intuitive, but a group of not-for-profit hospitals appear to be among those doing the best business.
At least, that’s the idea in a study published Monday in Health Affairs. It analyzes how hospitals make money and ranks the nation’s 10 most profitable ones — those making hundreds of millions of dollars through their inpatient and outpatient care. Seven were nonprofits, including the top four.
The findings are based on Medicare cost reports from fiscal year 2013, analyzing almost 3,000 acute-care hospitals. About 60 percent were nonprofit, while one in four were for-profit. The rest were public, or government-owned.
The top three were nonprofits. Gundersen Lutheran Medical Center, part of the large Wisconsin-based health system, made the most money: $302.5 million just on its patients. California-based Sutter Medical Center, also part of a large system, came in second. Stanford Hospital, also in California, was third.
Those hospitals share a key attribute, the authors argued. Whether because of their size, their prestige or their influence in the community, they have more power to negotiate prices, meaning they can charge insurers more for the care they give.
“They are the only provider — or they are clearly the dominant provider — and the insurers in that community are relatively weaker, and there are a lot of them,” said Gerard Anderson, director of the Johns Hopkins University Center for Hospital Finance and Management, and one of the study’s authors. “[The hospitals] can take advantage of their market position. And they do.”
The researchers looked only at profits made from actual medical care, meaning they didn’t factor in the often substantial amount of money hospitals make from sources like investments, grants, donations, parking fees and property rentals. The idea was to focus on what hospitals make from patients alone, said Ge Bai, the study’s primary author. Bai is currently an assistant professor of accounting at Washington and Lee University, though she’s joining the faculty at Johns Hopkins’ Carey Business School in the fall.
Most hospitals — particularly nonprofits — don’t actually earn money from patient care. Rather, a large market share or inclusion in a big health system — like Gundersen — better predicted how well hospitals would do.
“Many of the hospitals best-positioned to earn profits are non-profits — they’re the ones often that have the most prestige, they’re the largest hospitals,” said Paul Ginsburg, the director of the Center for Health Policy at the Brookings Institution and director of public policy at the University of Southern California’s Schaeffer Center for Health Policy and Economics.
Ginsburg, an expert in health economics, wasn’t affiliated with the study.
Market muscle matters in bargaining with insurers. That may be driving the hospital industry trend toward consolidation.
In recent years, many hospitals have merged to form larger health networks. They argue that doing so leads to better service to patients — for instance, care can be coordinated across more locations. In addition, they say they can then better negotiate with insurance companies. The study notes that in markets dominated by insurance companies, hospitals were less likely to profit from patient services.
But mergers have also been shown to increase the cost of health care. That’s because they often give hospitals leverage to set higher prices or charge insurance companies more. Likewise, brand-name hospitals, such as those affiliated with prestigious universities, can exert a similar pressure, Bai said. For instance, she explained, if she were shopping for health insurance in Baltimore she wouldn’t buy a plan that didn’t include Johns Hopkins Hospital.
Increased health care costs, the study authors said, are felt by consumers — either in the form of higher health plan premiums, or, in higher hospital bills for patients who don’t have insurance or who receive care out of network. The latter situation happens more often than people expect, Bai said, especially in emergencies, when people don’t have time to pick who’ll treat them.
The study also adds to the debate about whether the tax status of nonprofit hospitals needs more thorough scrutiny, Ginsburg said. They typically don’t have to pay taxes because, the idea goes, they provide a public service. But the paper’s findings “very clearly raise the issue about … whether these hospitals need or deserve the tax exemption.”
That’s an issue federal policy has tried to address, too. The 2010 health law, for instance, included a provision intended to make nonprofit hospitals prove they deserve their tax-exemption — increasing the standards for the “community benefit” those hospitals are supposed to provide.
Often, the local hospital is the largest economic engine in a community, and not taxing it means the local governments forgo a significant amount of revenue. The benefit a not-for-profit hospital provides hardly differs from that provided by one that’s for-profit, especially when both types of hospitals have rosy financial outlooks, based on the patient care, Ginsburg said.
Meanwhile, Bai said, the findings also support the notion that hospital mergers need to be better regulated. Setting federal limits on what hospitals can charge for a particular service might also help, she added. Maryland and West Virginia have experimented with that idea. Despite outcry from some executives, the study notes, hospitals in those states are still profiting.
Without that kind of oversight, Bai said, consumers will get shortchanged.
“We’re absolutely paying a higher price,” she said.