Union activity spiked in 2014, adding complexity to managing healthcare employees. Here's how to make union leadership your ally instead of a nemesis.
Unions might be coming soon to your hospital, if they're not already there, suggests Labor Activity in Health Care, the newly released report on union activity in healthcare updated semi-annually by the American Society for Healthcare Human Resources Administration (ASHHRA) and IRI Consultants.
Bolstered by new laws that buoy organized labor, union activity in hospitals is a growing trend. The federal Department of Labor reports that union membership in the United States climbed by 100,000 in 2014, to 14.6 million union members. In 2014, 359 petitions for union representation were filed within healthcare organizations. Unions were successful in 77% of 244 representation elections in the healthcare sector, making 2014 a very successful year for healthcare unions.
"Unions have become more active, certainly," says G. Roger King, senior labor lawyer and employment counsel at the HR Policy Association, an advocacy group for CHROs. King has counted many hospitals and health systems among his clients.
King attributes the increased activity to multiple factors. Upheaval in the healthcare industry stemming from the consolidation trend, hospital closures, and increased regulation around the PPACA and changes in delivery of care leading to uncertainty has benefitted union membership roasters, King says.
"People like to have certainty … and they may view union representation as an answer," he told me.
King also believes that the National Labor Relation Board's new election rule,which took effect in April, dramatically shortening the timeframe for holding a union election after a union's petition has been filed, has and will continue to benefit union growth.
Finally, concerns around staffing ratios and hot topics like flu shot mandates and fears around contagious diseases like Ebola and Lassa fever may have turned the attention of employees toward unions as well.
Getting past fear of unions
Few topics are as contentious and polarizing as union presence, or as daunting for human resources leadership to deal with.
"Unions create an additional layer of complexity, and make it so you have to deal with your employees through the union," says James G. Trivisonno, president of IRI Consultants and at-large member of ASHHRA's advocacy committee. "Union presence increases the risk of strikes. You're also looking at increased costs for administering labor agreements."
But union presence isn't the end of the world. In fact, it's possible to create a mutually beneficial rapport with them. "I think unions generally don't want conflict. Unions want to represent employees," says Trivisonno. "If your employees become unionized, accept that they became unionized. Don't fight it."
Here are a few different methods to foster a collaborative, rather than antagonistic, relationship with unions present in your hospital.
Strategy #1: Learn about unions If unions are new to your hospital, or you've never worked in a "union shop" before, make sure you and your hospital's leadership understand unions. "Contact some expertise," suggests King, who says a frequent mistake he's seen is that hospitals often rely on the same employment lawyer they work with for typical employment issues. This is the time to bring out the big guns; many employment lawyers are woefully uneducated about union issues.
"Get somebody in there quickly who knows what they're doing," King says.
While you're at it, educate yourself on union methods and learn why they exist and appeal to employees. Make a genuine effort to understand their agenda and see their point of view. Make sure you're well-versed. "You don't want to be playing catch-up," King says.
G. Roger King
Strategy #2: Find common causes Perhaps the best way to befriend someone you've had a contentious relationship with is to work together to solve a problem. You will likely have ample opportunity to do this with your local union.
For example, some employees just won't agree with anything HR has to say—but they might feel differently about feedback or a "no" answer coming from a union steward.
"When an employee has an issue or a grievance, sometimes they're being unreasonable," says Trivisonno. "But if the union steward and the hospital are on same page, and the steward can explain from the union's standpoint and the employee's perspective why their position is unreasonable, they can help explain the problem to the employee. This can be a situation all parties work together to resolve."
Beyond soothing aggravated employees, union leadership can also explain contracts, educate workers about job safety, and help enlist employees (and sometimes, the community) in cases where it is mutually beneficial.
Strategy #3: Reach out Don't hide behind your desk! This is one relationship you want to actively cultivate.
"Make sure you have a relationship with the union before problems start," King says. Make it clear to the union stewards that you want to maintain open lines of communication, and that they should feel free to come to you with any concerns they may have—preferably before these become serious, litigious affairs.
"You don't want to be defensive when talking to them. Be thoughtful of what you say, and be knowledgeable," he says. Joint trainings, mutually sponsored activities, and employee appreciation events can help grow your relationship and understanding with the union.
Managing members of a union can add a layer of complexity to HR's already labyrinthine duties, but it's important to remember that union leadership is primarily motivated by protecting their members, most of whom aren't looking for conflict. And unions have their purposes, King says.
"[Unions are] a good check and balance. Some people are very critical of unions, perhaps for good reason, but unions have been a part of our social fabric in this country for a long time and are part of our democracy," he says.
And it looks like unions are back in fashion—and likely to remain a part of the healthcare employment scene for the foreseeable future.
A campaign to remove barriers preventing physicians from practicing across state lines and promising to pave the way for further expansion of telemedicine continues to gain participants.
The tally of states at the vanguard of a movement that promises to alleviate physician shortages now stands at eight.
Alabama and Minnesota became the seventh and eighth states to enact the Interstate Medical Licensure Compact on this month, triggering the formation of the Interstate Medical Licensure Compact Commission. The commission aims to administer a streamlined process for physicians seeking to obtain licensure in multiple states. Greater license portability is expected to be a boon to the practice of telemedicine.
"We're hoping to have a few more before the end of the legislative year," says Lisa Robin, chief advocacy officer at the Federation of State Medical Boards (FSMB), speaking by phone in the organization's Washington, D.C. office.
The commission will meet later this year to discuss further administration of the compact. The body will consist of two voting members from each state represented. Physicians, executives and members of the public appointed to medical boards are all eligible to serve as members.
The expansion of the compactis the result of two and a half years of work between various state medical boards. One hurdle: "We had to show some people that the compact was not doing away with individual state licensure or going to diminish the ability of states to enforce their own laws," Robin says.
Several states have expedited the interstate licensing process for physicians, but the lack of a standardized approach is an obstacle to physicians wishing to practice telemedicine across state lines, and to provider organizations seeking to staff telemedicine programs.
Gaining Ground
In January 2013, FSMB organized a conference for state medical boards from around the country to examine more efficient methods and policies for licensure of practicing physicians and began creating the first drafts of what would become the compact. Wyoming was the first state to join the compact. Idaho, Montana, South Dakota, Utah, and West Virginia followed. Legislation is pending in Nevada, Texas, Oklahoma, Nebraska, Iowa, Illinois, Michigan, Maryland, Rhode Island, and Vermont.
"For physicians and their employers that have physicians practicing in multiple states, this will certainly ease administrative activities around getting licensed in those states," says Robin. Tithe compact allows state medical boards to streamline the licensing process and will allow participating state legislators, law enforcement and licensing boards to share information, as well as function as a mechanism physicians can use to distribute their information to states they wish to practice in.
"Usurp aspects of state sovereignty in medical licensure"
"Create a whole new level of bureaucracy that will add substantially to the cost of medical care"
"Force physicians participating in the compact to engage in costly, time-devouring proprietary programs with no proven benefit to patient care…"
Adjunct Process
"[The compact] will not replace the traditional pathway for getting a license, it's just an adjunct, if you will," Robin says. Physicians will have full licenses in each state they practice in, but the same standards for initial licensure will continue to be in place, and states will be allowed to maintain their own laws.
Lisa Robin
Licensure in each state is not automatic—physicians will have to apply for licensure in each state individually, and would be required to respect the rules and regulations of each state.
"One thing that makes this advantageous is that it allows boards to share information that they are perhaps barred from sharing now," says Robin, such as complaints lodged by patients. "The states, while acting in compact, would be able to share that information… it would prevent someone who has complaints against them or is under investigation in one state to practice in other states where they might be licensed."
Reporting of public actions and complaints against physicians will be mandatory if the information is requested by the board of a fellow compact state.
The compact also allows states to perform joint investigations and grants authority to subpoena information across state boundaries. And it allows state medical boards to ensure that disciplinary actions are recognized and responded to across state lines. "There are regulatory advantages for state boards as well," Robin says, adding that she hopes the compact will improve patient safety.
Robin expects Nevada or Illinois to be the next state to join the compact. "I think we'll see a total of ten to twelve states join in this next year."
Everything people are saying about ICD-10 isn't untrue. It's time to separate truth from fiction and fact from baseless fear.
So much anxiety and uncertainty hover around ICD-10 that the incoming president of the American Medical Association, Steven Stack, says his organization would prefer to skip it altogether. "Let's just get to ICD-11 and get it done properly," he told a reporter this month.
The reasons are many. There are reports of tanked productivity in countries where it has been implemented, leery clinicians, and questions about whether implementation will benefit patient care are just a few of the concerns.
Nevertheless, the time has come to make the change, says Debra Seyfried, director of health information management and ICD-10 management at University of Kansas Physicians. ICD-9 has run out of codes but "ICD-10 has room to grow," she says. She likens using ICD-9 to using a phone made in 1979, the year ICD-9 was introduced. "It might still work, but doesn't your new phone have many more features and capabilities?"
As the Oct 1st implementation deadline nears, Seyfried examines four commonly held concerns about the coming changes, and explains whether and why they are valid.
Fear #1: Productivity will plummet once ICD-10 is implemented.
Ruling: Valid
Debra Seyfried
Canada saw an estimated 67% drop in coder productivity after ICD-10 was implemented in a staggered rollout between 2001 and 2005, Seyfried says. "I don't believe they have totally recovered. Last I heard, they have recovered about 30% of the decrease."
But US hospitals have one advantage over Canada—more time for planning and training. The Canadian implementation placed little emphasis on training and it showed.
Mark Bogen, chief financial officer and vice president of finance at South Nassau Communities Hospitalin Oceanside, NY, says many hospitals have been actively trying to avoid the predicted drop in coder productivity, which can be considered a real threat to hospital cash flow.
Having taken the warnings seriously, South Nassau has invested heavily in technology upgrades to try to head off losses early. "We're already starting to see some productivity gains under the ICD-9-CM environment," Bogen says. The hospital's coders have been dual coding since June 2012.
Seyfried believes that the emphasis on training in the US and the level of preparation many US healthcare systems have implemented has led to a transition that has the potential to be seamless for many organizations. The key, she insists, is proper preparation and practice.
Fear # 2: ICD-10 is going to cause major glitches and technical problems with EHRs.
Ruling: Unknown
No one knows what's going to happen yet, which is why it's important to start dual coding In ICD-10 and bring any problems to the attention of EHR vendors.
"Now is the time to see where the documentation is and evaluate your need to retrain employees," says Bogen. "You can plan for every crisis possible, but until you live in the ICD-10 world, you aren't going to know how successful your implementation was."
Bogen's team has been preparing for the ICD-10 deadline since late 2011, ensuring that all staff are trained in both ICD-9-CM and ICD-10. He believes the training will help South Nassau's coders avoid unpleasant surprises come fall.
Jeannine Engel, MD, FACP
Jeannine Engel, MD, FACP, is associate professor of medicine and physician advisor of billing compliance at University of Utah Healthcare. She expects some interruptions, but cautions against panic. "The structure of the health record, the doctor-to-patient story—that is not going to change," she says. She does, however, have concerns around system issues and confusion caused by unspecified codes impeding the timely payout of claims.
"Could things get glitchy? Absolutely. I don't think individual systems will be problematic, but things like electronic billing have the potential to have some bumps in the road... Any time there's a changeover where there has to be communication, there's potential for problems," Engel says.
Fear # 3: ICD-10 is incredibly complicated and hard to learn.
Ruling: Good news/bad news
The good news is that ICD-10-CM is not overwhelmingly different from ICD-9-CM."It depends on which part of ICD-10 you're talking about," says Engel. "ICD-10 diagnosis coding is not difficult to learn. Honestly, it's no harder than ICD-9-CM is."
ICD-10 PCS, however, is another story. "It's very different from ICD-9-CM procedure coding. I would say from having done it, it is more difficult to learn. Please note, I am saying it's difficult. Not impossible. It's a different coding schema."
While ICD-10-CM has been implemented in every foreign country that currently uses ICD-10, giving us a sneak peek into issues we might expect, the United States will be the first and only country using ICD-10-PCS—meaning that we have no preview regarding what might go wrong.
Bogen worries that clinician holdouts could be a problem. "The big concern is always the physicians." A frequent nightmare is that poor documentation and stubborn medical staff will lead to delayed or rejected payments.
However, Bogen hopes that physicians and other clinicians take documentation a bit more seriously as Medicare payments become increasingly tied to their accuracy. "We'll see whether or not medical staff is able to respond appropriately and be that much more specific," he says.
Fear # 4: ICD-10 won't change anything.
Ruling: Invalid
ICD-10 promises to spur population health programs by supplying a high level of diagnostic specificity about illnesses among large groups of people and clinical outcomes.
Mark Bogen
"These changes are primarily going to improve a lot of things based on population health, since more specific diagnoses coding allows for better gathering of information on a population or group basis," Engel says. While these benefits likely won't be seen for years, the data is expected to be beneficial not only to patients and clinicians, but also to healthcare leaders and payers.
But more and better data comes with challenges and changes to how some people do their jobs. Says Seyfried: "I think many clinicians will want to find someone else to do billing and coding for them. There is going to be a higher demand for coders in the near future," she says.
But what's important now is to get all hands on deck and prepare employees for these changes. "If you haven't started by implementation yet, you're really asking for trouble," says Bogen.
Seyfried's advice is to make employees the focus of an ICD-10 transition. "Give them plenty of feedback… It's important to do it now, not on D-Day," she says.
Frustrated with the variable quality and supply of temporary workers, a California health system finds a reliable solution for temporary staffing challenges.
There are two main strategies for dealing with temporary staffing needs in healthcare. The first is to work with agencies to fill temporary gaps in staffing and find new talent; the second, which is less common, is to create your own pool of temporary employees to draw upon.
"People who are not part of your organization and who work for a vendor just don't have same commitment to the workplace," says Vic Buzachero, corporate senior vice president for innovation, human resources and performance management at Scripps Health in San Diego. "When you create your own pool of temps, the temps become a part of that organization's culture and share in everything."
Vic Buzachero
While Scripps was once a major customer of several healthcare staffing groups, it decided to experiment with creating its own temp pool in 2009. Starting with 25 nurses, the temporary worker program, called Scripps System Resource Services (SSRS), has expanded to include more 700 such as pharmacists, nursing assistants, respiratory therapists, operating room staff, IT professionals, project managers, registered dieticians, cooks, food service workers, and administrative positions.
"It is an excellent feeder mechanism for us, along with our normal recruitment process," says Buzachero, who spoke with me about how his organization's created its own pool of temporary workers. This transcript has been edited for brevity and clarity.
HLM: How many of your temps will likely be hired to work for Scripps Health permanently?
Buzachero: There are about 700 people in our SSRS pool. About one-third of these staff will convert to regular employees somewhere within our organization each year. Growing the pool is really a challenge. Not only do we have to backfill the third who become permanent employees, but we have to bring in larger numbers. We are currently seeking to double the size of the pool. It has grown by about 100 people in the last year.
HLM: What are some potential pitfalls of using externally sourced temporary workers?
Buzachero: Any time you bring in people from outside organization on a temporary basis, they're not as familiar with systems and practices of the organization they're working with. All health systems and hospitals are a little different, and every role is a little different. Systems that are used, whether they be pharmacy control, charting, and so on, are all dependent on types of information systems you have.
If new, or certainly for a temporary worker, you might not be as familiar with everything that takes place within an organization. Not knowing the ropes is a real challenge. When we do have patient incidents, more than 50% of them can be attributed to an outside person. That number motivated us to create our own pool, so we have people who are familiar with our systems and processes.
HLM: What are some issues with temporary workers that are unique to healthcare?
Buzachero: The first is the bonding with a team. Healthcare teams work so intensely providing patient care that those teams bond very tightly. A temporary worker coming in is just like a new kid in school; you don't know anybody and you don't get a lot of help. Everyone's a highly trained professional, and it's assumed that, as a highly trained professional, you know what to do. That's a tough culture to walk into.
Second, there are certain legal requirements that we must go through in employing them. In other industries, you can hire anyone to do anything, but in nursing, for example, your nursing license only permits you to do certain things. Especially if you go from state to state, as each state has different regulations.
Which is another advantage of having our own pool. We're not pulling people from other states, and are not trying to learn what nursing means in California as opposed to Texas or Washington. The clinicians in our pool are all licensed locally.
HLM: What kinds of experiences has your organization had working with temporary staffing agencies?
Buzachero: We used to work with many different staffing agencies. Once the pool was started and in full swing, we were able to avoid working with them again until this year. We're currently using a few staffing agencies. No one staffing agency can meet all your needs, and, as a result of that, you may end up dealing with a large number of different staffing agencies.
If you asked even the biggest healthcare staffing agency in the country to send you 100 registered nurses, they wouldn't have 100 to send you. They might have 10, or 15. In another month, they might have another 10 or 15, but they couldn't fulfill your needs. Another challenge is that each agency has a different definition of quality and caliber of people, so you get great variability in the [quality of] people.
We do still have a relationship with some staffing agencies, but we're no longer a big volume client. We've hired on 38 people from agencies this year. Before we created our temporary worker pool, we sometimes had many as 500 people from agencies annually. You can imagine the nightmare of trying to manage all of those people from different agencies.
HLM: What further advice do you have for HR leaders considering bringing in temps, either supplied by an agency or from their own pool of workers?
Buzachero: Your patients are trusting you at their most vulnerable moments; the last thing you want to do is leave them with someone you don't know very well. They're trusting you with their lives. I think that's one of the key things about healthcare, and a perk of using your own pool to staff your temporary needs.
It's easy to run afoul of the Fair Labor Standards Act. But violations are entirely avoidable.
The Fair Labor Standards Act (FLSA) isn't always straightforward—and it is frequently infringed upon unknowingly. In some circumstances it may be beneficial to consult with an employment lawyer.
To review the FSLA basics, I talked with Thomas Shorter, a healthcare employment attorney and shareholder at Godfrey and Kahn, in Madison, WI. He had shared these three common FLSA errors with me in February:
Misclassification of employees as exempt
Time-tracking errors
Comp time blunders
This week I'll share three more areas where employers must be careful, according to Shorter:
1. Classifying Employees as Independent Contractors or Consultants It can be tempting to classify an employee as an independent contractor, especially if he is new and no decision has been made on whether to hire him full-time or permanently.
Thomas Shorter
But this would be a violation of FLSA, says Shorter.
"You can only do that if the individual legitimately meets the definition of an independent contractor. In more than half the cases that are brought to me with that scenario, it does not qualify. They're your employee. To attempt to classify them as an independent contractor is taking on major risk as a healthcare system."
What qualifies someone as an independent contractor? Does he have his own company or an LLC? Are you being billed by a consultancy for his services? Does he carry insurance that covers him for acts of negligence on the job? "Real consultants are part of a company," says Shorter.
"If the answers to these questions are no, then these are markers to me that the organization is thinking, 'I want them to be a temp that I don't have to worry about FLSA for.' And that is a big risk," Shorter says.
Many organizations have misused the independent contractor or consultant classification to avoid paying for benefits, sick time, vacation time, or unemployment insurance, but Shorter warns that it is a very risky proposition. "States have gone after many employers, including healthcare systems," he says.
Bottom line: Understand the law, and make hires accordingly.
2. Overtime and Stand-by Errors Here's another easy FLSA error to make, especially now as the industry continues to consolidate.
Frequently, says Shorter, a healthcare system will operate multiple hospitals or other facilities. Each may even be its own separate legal entity, yet still part of the same corporation.
The problem is this: "You find scenarios with a nurse, CNA, or other non-exempt employee working at two locations, but HR fails to connect the dots." It most commonly occurs when a healthcare system buys a hospital where a nurse or CNA was working extra hours nearby.
Frequently, no one notices that the employee is working 40 hours weekly at the primary hospital, and 15 in the second and getting paid at the nominal rate.
Is it a problem? "Yes, unequivocally. The employee is working 55 hours collectively, and getting paid at a base rate. It's almost a joint employment situation—and so easy to fall into in a multiple hospital system."
Stand-by compensation is also frequently forgotten in healthcare—if you tell someone to watch his pager or stay by his phone, he should be earning stand-by pay.
3. Abominable Side Agreements Many employees are asked by misinformed managers to work off the clock, to forgo overtime, or to work on a day off in exchange for extra pay the next month, a catered dinner, a gift, or a day off later in the month (also known as "comp time") in lieu of overtime pay.
But these are all violations of FLSA law.
While some managers think it's alright to "work something out" with an employee if there isn't any overtime left in the budget, overtime hours stretch on longer than expected or an employee chooses to work off the clock to finish something up they couldn't get done during regular business hours, that is incorrect, says Shorter.
"Payment must be in cold, hard cash only," says Shorter. While the employee might say he would prefer to leave early on Friday, receive a gift certificate for a favorite store, or enjoy an expensive dinner paid for on the company credit card, those options are simply not legal.
It's also not legal to agree to pay an employee in the future for work performed now. If an employee works overtime during this week's pay period, he must be paid for those hours when he is paid for the other hours worked this week—you cannot defer them or make them up in at a later date.
It's easy to run afoul of the FLSA—but avoidable with better awareness and understanding of the law.
While the U.S. economy slowly recovers, healthcare jobs have skyrocketed, benefiting from favorable federal policies and greater access to care.
Healthcare employment hit a new milestone in April when the sector surpassed 15 million jobs, with 390,000 new jobs created in the past 12 months, Bureau of Labor Statistics jobs data show.
In April, healthcare grew 45,000 jobs, including 25,000 in ambulatory care, 12,000 in hospitals, and 8,000 in nursing homes and residential care.
Healthcare job growth for the month was outpaced only by employment in professional and business services, where 62,000 new jobs were created in April, but healthcare still tied with construction for the second-fastest growing employment sector in the country.
Expanded Access and an Improved Economy
"This has really been a sustained increase in employment, month-over-month," says Thomas Wickizer, PhD, professor and chair of the College of Public Health at the Ohio State University. "I think in part it is the effect of the PPACA (Patient Protection and Affordable Care Act) that has brought more people in to the [healthcare] system through expanded insurance coverage."
As an estimated 22.8 million Americans previously without health insurance got coverage between September 2013 and February of this year, demand for medical services increased—much of that in ambulatory care settings. "Overall, the aggregate effect of that is to increase the demand for number of different allied health occupations," Wickizer says.
Additionally, a slowly improving economy might have some influence in increased demand for healthcare services, says Katherine Baicker, professor of health economics and acting chair at the Harvard T.H. Chan School of Public Health.
"The first thing to realize is that healthcare employment and healthcare spending are likely pro-cyclical, meaning they are higher when the economy is doing better," Baicker say. "While some healthcare use is not sensitive to economic conditions, many patients put off elective procedures during uncertain economic times."
Baicker points to an improving economy combined with increased volume in outpatient procedures as factors driving ambulatory job growth.
She warns against viewing these new jobs in healthcare as a "fix" for the economy. "We don't want to think the goal of health reform is promoting health employment," she says. Baicker says the healthcare sector should strive to reach the same health outcomes using fewer resources, employees and procedures to keep costs down.
"In general, people are very excited when there's job growth, and for a good reason," Baicker says. "But we need to think carefully about what it means to have higher employment in the healthcare sector, because that's likely to translate to higher healthcare spending and higher health insurance premiums, which can make healthcare less affordable overall."
Additionally, the unemployment rate and number of unemployed people are essentially unchanged from last month, but the overall number of unemployed workers has dropped slightly, by .8%. 191,000 jobs have been added to the economy overall since February.
The actions taken by an organization in the days, weeks, and months after a security breach can mean the difference between recovery and organizational failure—whether the breach is a result of criminal activity or "good people doing stupid things."
Three words healthcare executives dread hearing—"we've been hacked"—are reverberating in hospitals, health systems and physicians groups with growing frequency.
Most organizations will experience a data breach at some point, says Elizabeth Hodge, of counsel at Akerman LLP, a lawyer representing a variety of healthcare organizations in compliance-related matters from her firm's West Palm Beach office.
"If you are a healthcare entity, you should anticipate that you will have breach of unsecured health information at some point," she says.
The Ponemon Institute, a data security research and consulting firm, found in its annual benchmark study that healthcare providers experience frequent data breaches involving the loss, even the theft, of patient health information.
About 90% of healthcare organizations were found to have had a data breach within the last 24 months. "These are not like Anthem," says Larry Ponemon, PhD, the firm's founder and chairman. "We're talking, 10, 20, maybe 100 individual records [involved]." While the numbers of patients who have had personal data leaked might not be as high as a massive breach like Anthem's, the implications for those people are no less troubling.
Social security numbers, credit card information, and other private data is valuable. But the "crown jewel" for a data thief, Ponemon says, is a full medical record, which can fetch a criminal as much as $250.
Frequently, the information is used to impersonate the victim or set up a fake identity. A full chart with headers contains personal data, payment information, and often social security numbers which can be used to obtain medical treatment.
"This kind of crime is on the rise. These criminals use medical credentials to get healthcare and pharmaceutical products. We've seen them get cosmetic surgery, scooters, all kinds of treatments," he says.
Organizations are often taken by surprise. "A lot of providers are unable to know with precision whether they've had data breach, or if data has been lost or stolen," Ponemon says. While some breaches are due to malicious intent, data is often lost due to a glitch or error, which are unlikely to be reported.
And even when IT or security is aware of a breach, the news doesn't always make its way up the ranks to the organization's leadership.
Be Prepared
Dealing with a data breach really starts by being prepared for it, says Hodge.
"Before the breach ever happens, from a legal and good business planning perspective, you should anticipate that you will have a breach of unsecured health information at some point in your business' life," she says.
Elizabeth Hodge
Decide ahead of time who will be responsible for handling each process and have a plan in place. Hodge suggests that all stakeholders across the organization be involved. "You want the head of the IT department involved… if you have a security officer, you want that person involved, too," she says. Any in-house counsel will need to work on this issue as well, and likely the hospital CEO.
Insurance may help defray the costs of responding to a breach, but as the Department of Homeland Security confirms, the cybersecurity insurance market is young and confusion about policy costs and coverage is abundant.
Communicate Carefully According to HIPAA regulations, organizations have 60 days from date of discovery of the breach to provide notice to patients that their data has been compromised. "There is an exception for situations where law enforcement has requested a delay in notifying patients beyond that window," Hodge adds, although those are fairly rare.
While regulations vary state by state, most require patients to be notified in writing, via US mail. "If there is an emergency situation, you can provide notification via alternate means, such as telephone, but follow up in writing," suggests Hodge.
Publicly announcing that there has been a breach can inadvertently make the situation worse if it is done too soon. One consequence of announcing a malicious breach prematurely is that it can alert the criminals that they have been discovered, which can foil any opportunity to properly investigate or track them down.
And an announcement made before the extent of the breach is known can discredit an organization. "What you don't want is to say on Monday, 'We've experienced a data breach of 30,000 medical records,' then, on Tuesday, come out and say, 'we were wrong, it was one million records'—only to come out a week later and say it was actually 27 million," says Ponemon.
Hodge also warns against speculation when talking to outside parties, whether they be the media, patients, or anyone else, which can be difficult when confronted with tough or angry questions without apparent answers. "I would say that we need to be truthful and communicate what we know," she says.
Showing real concern for those impacted is important, however. "Communicate that you take such incidents seriously. Describe efforts that you and your organization are taking to fix the situation," she urges.
Also, Hodge advises not to give too much detail regarding measures the organization takes to protect against future breaches, as that might put the electronic data in even further trouble.
Damage Control Once the public has been made aware of a breach, the next step is to focus on repairing relationships with customers (patients). In the past it may have been considered a bad idea from a legal perspective to apologize for a data breach, but that is no longer the case.
"There are ways to apologize that someone's info was accessed without accepting blame," Hodge says. "Maybe you can't escape that perhaps your employee did something they should not do, but I think that in most notice letters I've seen, the entity does make an attempt to express regret for the incident."
She believes that refusing to express regret rather than issuing a simple apology is more likely to inspire customer outrage or a potential lawsuit.
Ponemon's research suggest she is correct, finding that 43% of customers will return to an organization that leaked their information if they receive a heartfelt apology. Additionally, Ponemon and Hodge both suggest offering impacted patients free credit monitoring services and legal assistance should they become victims of identity theft as a result of a breach.
Despite portrayals in film and TV, the majority of breaches are not easily traced within hours. It can take weeks or months to determine the source of a leak, and the full extent of the damage. It's also possible there will be unpleasant surprises once the source comes to light.
"It's one thing if the records were infiltrated by an outside actor, but it's different if one's own employees may have been improperly accessing records internally," says Hodge.
As many as 75% of data breaches are estimated to be "inside jobs," although many are not intentional. "As more organizations are relying on non-expert IT people, these situations are becoming more prevalent," says Ponemon. "A lot of these incidents are just good people doing stupid things."
HR doesn't have to be a bystander in the push toward population health.
The HR suite might seem like an unlikely place to define, implement, or advance population health, but its unique position as "the heart of the hospital" gives it the opportunity to kickstart the concept and move beyond buzzword status.
While most healthcare leaders acknowledge that population health is an important theme within the value-based purchasing model, there little awareness among patients, and even some clinicians.
Leonard Friedman, PhD, MPH, FACHE
"I don't think the general public really knows about [population health]," says Leonard Friedman, PhD, MPH, FACHE, and director of the master of the health administration program at the Milken Institute School of Public Health. He recently conducted a study which asked more than 35 healthcare leaders to define population health. The responses were extremely varied.
"We need to be able to speak a common language. If people have multiple definitions of what 'population health' means, we're talking past one another," says Friedman.
"Hospital leadership is in a very special position," to rectify that, he says. Friedman points out the advantage hospital administrators have in helping to foster collaboration within different areas of healthcare—among social workers, community leaders, and public health officials:
1. Educate the Community Often the largest employer in the area, a hospital can be "a beacon in its community," says Friedman. A hospital is often ground zero for major life events—it's where people go when they are ill or hurt, when a new baby is born, or for shelter and help during a natural disaster. As a result, hospitals are already integral parts of their communities.
Some have already started outreach programs with activities that include setting up booths at local festivals, sending out community newsletters, using social media, or visiting neighborhood organizations to inform them of population health-related topics such as the dangers of tobacco use, the importance of carrying health insurance, or why wearing a seatbelt matters.
Other activities include promoting programs which help families secure access to healthy foods, providing free or low-cost health screenings, or distributing literature about conditions prevalent in the community, such as obesity, addiction, cancer, and domestic violence.
2. Upgrade Care Coordination "My mother passed away five years ago this month," says Friedman. At the time of her death, she was under the care of 10 different physicians, each handling a different component of her care. When he went to Los Angeles to be with her in her final moments, Friedman was surprised to learn that none of his mother's physicians had ever communicated with each other until right before her passing, when a dedicated hospital social worker insisted that every stakeholder involved in the woman's care gather in a room to discuss her situation. Friedman saw it as a lost opportunity for proper care coordination.
"We are in an immensely broken system," says Friedman. "People don't talk to one another, and we don't coordinate care." His mother's experience opened his eyes to the importance of care coordination and population health implementation.
Unfortunately, this is not an isolated incident, but one that plays out in hospitals every day. As complexity of care grows, proper coordination and management of that care is increasingly important.
One solution might lie in hiring social workers or nurses who specifically deal with care coordination and oversee patient care plans, ensuring that all clinicians involved in a patient's care stay abreast of that patient's condition. Some organizations have found it helpful to employ care coordination teams to oversee each patient's care.
3. Plan for Population Health
But Friedman believes things are moving in the right direction. He says most healthcare leaders he knows recognize that population health is here to stay.
"There's much broader recognition for need of population health and population health management than there used to be." The HR suite must recognize that population health is becoming a key part of healthcare strategy and must begin to incorporate it into the greater plans of the organization, in terms of hiring, and other hospital policies.
"Trying to do the right thing and develop workable strategies as to how public health is implemented is the next step," says Friedman. "And I think we're starting to move down that road."
Long lacking regulation, employee wellness programs offered as part of an employer's group health insurance are the subject of a proposed federal rule designed to protect privacy and prevent abuses. Here's what HR leaders need to know about it.
Few HR topics have the potential to be as controversial as Employee Wellness Programs (EWPs).
EWPs are purported to help encourage workers to adopt healthier lifestyles, which may, in turn, encourage healthier, more productive employees while decreasing absenteeism and health care costs.
A proposed EEOC rule could change things. It would provide new guidance to both employers and employees regarding how wellness programs offered as part of an employer's group health plan must comply with the Americans with Disabilities Act (ADA). The public comment period is open until June 19.
Peggy Mastroianni
I spoke with Chris Kuczynski, acting associate legal counsel, and Peggy Mastroianni, legal counsel, both of EEOC, recently to learn how these proposed changes would impact EWPs. The transcript has been edited for brevity and clarity.
HLM: Can you describe the proposed rule?
Kuczynski: This is a proposed rule primarily about employee wellness programs that ask questions about employees' health or require medical examinations, including blood pressure screening, cholesterol screens, or blood glucose screens where you're drawing blood and trying to determine someone's health status.
Some of these programs just require people do something that doesn't involve asking health-related questions or medical exams—things like taking a nutrition class, a smoking cessation class, or a weight loss support program. Employers have obligations in respect to those kinds of programs to provide reasonable accommodations for employees with disabilities who participate in those programs, such as providing a sign language interpreter to hearing impaired employees who wish to attend these classes.
But, this rule is really about wellness programs that seek medical information about their employees. The ADA allows employers to get that health related information from employees as a part of workplace health programs, as long as answering the questions is voluntary on the part of the employees.
HLM: Under the proposed rule, what could an employer do with the results of an employee's screening?
Kuczynski: These programs can't impose or be overly burdensome to employees. They can't evade or violate EEO laws.
Here are two examples of things that are okay under the proposed rules. The first: An employer does a health risk assessment, then gives employees information about what their health risks are. Second, they can use the health risk assessment data to look at the aggregate information about the health status of their workforce, then use that information to design programs that will improve those conditions.
Now, what's not OK is not using that info at all. They must use that information.
It can't just sit there unused, with no benefit given to employees. Just sort of collecting information about employees is not acceptable.
HLM: I've heard some organizations require employees to participate in EWPs. Will that requirement still be allowed?
Kuczynski: What the second part of the new rule means is that health program participation, including answering personal questions or having medical exams, is required to be voluntary. A program is not voluntary if employees are required to participate in the program, or if they're denied health coverage if they decline to answer questions or participate. It's rather obvious under the ADA already.
You can't require people to participate, or require them to answer personal questions. You can't deny health coverage based on wellness program participation, or limit coverage in ways other than is permitted concerning incentives.
There is also a ban against retaliating against anyone not participating or achieving stated wellness goals, taking adverse action against employees, disciplining them, coercing them, interfering with their ADA rights, or threatening them with discipline.
HLM: What about employee privacy?
Kuczynski: If wellness programs are part of a group health plan, it must provide a notice to employees about several things: What information is going to be collected as part of the program, with whom it's going to be shared, how it's going to be used, and what measures are going to be in place to protect confidentiality.
Confidentiality is a very important part of this proposed rule, and measures to protect confidentiality are very important to encourage people's participation in these programs. People are less likely to participate if they don't believe that the information will be kept confidential.
Also, employers should only be getting employee information back from wellness programs in aggregate form that does not reveal the identity of employees. [Employers] might know they have a number of employees that have diabetes from participation in health risk assessments, for example, but they should not know who those people are.
HLM: What about financial incentives for participating in the wellness program or meeting health goals?
Kuczynski: Certain incentives, financial and otherwise, are permitted as part of a wellness program that is part of the group health plan. If the incentive is tied to health insurance costs and dependent on reaching certain health goals, the level of the incentive can, at maximum, come to 30% the cost of self-only coverage through the company's health plan. That's the total cost toward the premium, as paid by both employee and employer.
For example, if the company self-only plan cost $6,000 yearly, the maximum allowable incentive would be $1,800.
HLM: Is the EEOC aware of any abuses related to employee wellness programs?
Mastroianni: We have brought two lawsuits which are still pending. We don't know how they're going to turn out. The charges have been brought to the commission and investigated. We're currently in court on them. The cases involved actions like employees being terminated because they declined to do a health risk assessment or participate in a wellness program.
In both cases, the full cost of health insurance was transferred to the employee rather than the employer paying part of it. These are examples of things that can happen with EWPs. Currently, these cases are still just allegations, but we'll find out more as the cases progress. These are examples of things that can happen in some workplaces.
Kuczynski: Other types of abuses can occur, especially breaches of confidentiality. Confidentiality requirements apply to everybody, not just people with disabilities. You can't disclose anybody's medical condition, whether they're considered an individual with a disability or not.
But, for people with disabilities, those kinds of disclosures, particularly if they're stigmatizing types of disclosures—things people might not want people in the workplace to know about—privacy violations can be particularly problematic. People with disabilities tend to be much more worried about the impact such a disclosure might have on future employment prospects.
HLM: What advice do you have for HR leaders?
Kuczynski: My advice would be to go and look at resources our organization has provided on the proposal we're making. In addition to the rule itself, we have a brief Q & A document that can help healthcare leaders and EWP administrators understand the main components of the proposal.
We also have a fact sheet for small businesses, but businesses of any size are welcome to read it, and might find it helpful.
An annual survey of nearly 20,000 physicians finds a modest increase in average compensation, but a dip in job satisfaction across 26 medical specialties.
Physician compensation has seen modest gains since last year—but satisfaction has not risen along with pay, data from Medscape's Annual Physician Compensation Report shows. The report is analyzes how compensation influences physician career considerations and job satisfaction.
Now in its fifth year, the survey of more than 19,500 physicians across 26 specialties reveals that most physicians saw a modest increase in pay in 2014, and that employment status, therapeutic specialty, and gender were the key drivers for physician compensation.
The report also finds that the average primary care physician earns $195,000 per year while the average specialist brings home $284,000. Orthopedists, cardiologists and gastroenterologists top the best-paid specialists list, while pediatricians and family medicine specialists are the least-well compensated.
Additionally, the report shows that self-employed physicians (32%) earn substantially more than those who are employed (63%). On average, self-employed primary care physicians earn $212,000. Their employed counterparts earn $189,000, and self-employed specialists, on average, earn $329,000 compared to employed specialists ($258,000).
Only rheumatologists and urologists saw a decrease in compensation. Among the specialties with the greatest increases in compensation were infectious disease, and emergency medicine doctors.
But physicians bringing home the largest pay checks aren't always the happiest, the report suggests.
"Docs are generally happy with their decision to practice medicine, but we've seen some changes with their level of job satisfaction," says Michael Smith, MD, medical director and chief medical editor at Medscape's parent, company, WebMD.
"In past reports, we've seen their level of satisfaction… in the upper sixties [in percent of respondents who would choose to continue practicing medicine if they could redo their career]. We're now kind of getting into the low to mid-sixties," Smith said by phone.
The study reveals that poor morale, frustration around changes in the US healthcare system, and concerns around financial uncertainty are common grievances among physicians.
The Drivers of Dissatisfaction What makes for a miserable MD? Asking physicians to spend a lot of time doing paperwork, dealing with insurance companies, or performing other menial tasks that take them away from doing what they love, are all considered to be unsavory tasks, says Smith.
"What drives satisfaction for physicians is being very good at their jobs and developing strong relationships with their patients. Many of them feel that changes in healthcare are decreasing the amount of time physicians can spend with patients."
An unexpected finding is that physicians in several of the higher-paying specialties, including both general and plastic surgery, report lower satisfaction rates than some lower-earning physicians.
"Money is important, but we know from our survey that is not a driving factor. When you look at the types of specialties and the level of satisfaction, there's really no correlation there. Some of the physicians who had the highest compensation are also the least satisfied with their jobs," explains Smith.
"We see that the highest level of dissatisfaction is actually among those who make the most money."
Among the specialties, dermatologists were most likely to be content with their careers, with a 63% overall satisfaction rate and 73% saying they would reselect their specialty if given the opportunity to start their careers over again.
Internists reported a 45% overall satisfaction rate and only one in four said they would choose the same path if given the opportunity for a career do-over.
Ladies Last The report finds a 76-cent to each dollar pay gap between male and female physicians. "There's no doubt that we continue to see a difference," says Smith, who suggests the likely driving factors of the pay difference to be choice of lower-paying specialties among women and fewer hours worked on average by female physicians, even when employed full-time.
"Fewer hours worked would likely translate in to fewer patient interactions, and therefore lower income," he explained. Female physicians are also less likely than their male counterparts to be self-employed, with only 23% in private practice, compared to 36% of their male colleagues.
On a positive note, the overall percentage difference between men and women has decreased slightly since the 2011 Medscape report, falling from a 28% difference to 24%. The specialties with the highest number of female physicians were women's health and pediatrics, which are tied with an even split between the genders, while the specialties with the lowest female representation were orthopedics and urology, with 9% and 8% of specialists being female, respectively.
Other findings included a dramatic jump in ACO participation, up 900% since 2011, and decreases in both concierge medicine and cash only practices in 2014, as well as an increase in employed physicians—a trend Smith predicts will continue.
"I think we'll continue to see an increase in [employed] physicians in the year ahead," predicts Smith. "Employment comes with the benefit of being able to spend more time with your patients—which is what drives job satisfaction. They're the reason why many physicians go in to medicine."