Some frontline workers have everything it takes to move up—except a college degree. Boston Children's Hospital found a way to help them, and improved employee engagement and retention along with skillsets.
The Robert Wood Johnson Foundation estimates that one in every five nurses leaves his or her first job within one year and one third of nurses leave within two years. This drives down retention rates and creates a constant state of retraining, understaffing, and organizational frustration.
Loh-Sze Leung
So, where can you find employees who will be aligned with and understand your organization's goals and values? They might be right under your nose.
Some hospitals and healthcare systems are turning to frontline worker development programs to grow their own staff—especially nurses, but also medical billing and coding specialists, processing roles, allied health positions and administrators, says Loh-Sze Leung.
Leung is a nonprofit consultant who until recently was the executive director at SkillWorks, a Boston-based initiative that helps to connect employers with organizations that provide training to current employees interested in learning more skills applicable to their current fields (she still works with SkillWorks in a consulting capacity).
Since 2009, Boston Children's Hospital (BCH) has been developing dedicated frontline workers into educated professionals with skills that are in demand though its Bridge to College program.
The frontline trenches are a good place to start looking for your next healthcare leaders. The largest growth in employment within the healthcare sector over recent years has been among lower-paying, pre-baccalaureate occupations, but most jobs in healthcare that offer a living wage require an associate's degree or above. A college education is often out of reach for students from modest backgrounds, and therein lies the problem—and the opportunity.
Leung estimates that 140 of BCH's employees are either currently taking classes or have completed a degree through the Bridge to College. Five years and 140 employees later, BCH and its partners have learned some valuable lessons about tuition reimbursement, professional development and maintaining a pipeline of skilled workers.
1. Partner Up
BCH did not do this alone—its HR department collaborated with numerous organizations, including SkillWorks, CareerStat, an employer-led national organization that promotes employer investment career development of frontline health care workers, and Jewish Vocational Services, a Massachusetts-based group that assists with career development and training.
For non-traditional students, going back to the classroom can be daunting, especially if refresher courses in basic math or English are needed. Luckily, BCH was able to work with Jewish Vocational Services to prepare candidates for college level work.
BCH provided free training to its employees.
The cost, (shared with SkillWorks) of about $6,000 per participating employee per year assured that frontline workers had computer literacy, college entry-level math, and necessary English skills. It also meant that when the students attempted college-level courses, they would be ready for them.
2. Offer Tuition Assistance Up Front
College-level courses may be prohibitively expensive on a frontline worker's wages. So rather than reimbursing the employee after successful completion of a course, BCH paid tuition up front. If the employee passed the class with a C-grade or above, the student didn't have to pay a dime.
"Over a four-year period, only two students have not passed one class each," says Leung. "For part time students who are also working and have other responsibilities, that's a high rate of success." BCH's program also closed a gap in tuition reimbursement by covering the cost of certifications and certificates, which traditionally are not covered through tuition reimbursement programs.
3. Start Small and Get Buy-In
BCH started its frontline worker development program with a pilot, rolling it out in one department, with students who were destined for high-growth, high-demand courses of study. As the program become a success, BCH began expanding the program to other departments and more areas of interest.
As the program spread to new departments, human resources worked with managers in those areas to ensure early release for employees heading to class, plus encouragement and support. "That support helps them get through [higher education]," says Leung. "This program really requires buy-in and support from frontline supervisors and managers to be successful."
While some supervisors have expressed concern that their best and brightest will move on once they finished school, many have been happily surprised to see that workers become more engaged in their work after taking advantage of educational benefits. "Their performance gets better, their morale gets better," Leung says. "It's not just about 'what's the next step?'"
She suggests that HR leaders interested in starting similar programs start by looking into their own organizational staffing needs. "Make the case for supporting this sort of program. Examine what the needs are within your institution and go from there," Leung says.
"Most students who have engaged [in the program] are still on the path to achieving their professional goals," she says—and BCH will have a full pipeline of employees who are prepared for careers in healthcare.
More staff and more beds are not the answer. To prevent overcrowding in the emergency department this flu season, start with challenging accepted practices, bolstering leaders, and promoting a culture of efficiency.
Let's face it: resources are limited. You can only hire so many surgeons and so many nurses. Your hospital has only so many rooms, and so many beds. And, of course, there are only so many hours in every day.
During flu season, this is not something hospital management wants to hear—and neither do the sick, scared and feverish patients waiting in your emergency room. Especially this year.
With the recent Ebola hysteria still fresh in the public's mind, waiting rooms will be more crowded than ever this flu season, predicts Eugene Litvak, PhD, president and CEO of the Newton, MA-based Institute for Healthcare Optimization.
"We anticipate a spike in patients seeking emergency treatment—that always happens during the flu season—but it will be even worse with the current Ebola fears," says Litvak. He predicts unprecedented demand followed by unprecedented mismanagement of capacity in the coming months.
But with some organizational changes, it's possible to minimize the backups, he says.
1. Improve Patient Flow A common cause of backed up emergency departments is inefficiently scheduled surgeries. Certain times of the day or week are popular with surgeons, and it's not uncommon for two surgeries by different surgeons to be scheduled back-to-back. The problem arises when one runs over, causing multiple employees' and patients' schedules to run behind.
This practice also causes more beds, rooms, doctors, and nurses to be occupied by post-surgery patients, all at the same time—which wouldn't be an issue, except that during busy times, patients don't stop coming through the emergency department door.
But there is a strategy that can get the peaks and valleys of demand under control.
"It's much easier to admit patients through improved scheduling—it puts your organization in a better position to meet increased demand. This is how to prepare [to have the] capacity for increased demand," says Litvak.
Litvak uses the example of Cincinnati Children's Hospital, which was able to streamline its patient flow through improved scheduling practices. The organization has since been able to increase surgeries performed by 7%—but there was an even more important effect.
Due to the reduction in congestion, surgeons, ED staff, and nurses experienced a 57% drop in extended hours worked, improving work/life balance. The improved efficiency allowed the hospital to save $115 million yearly, says Litvak.
2. Hire Strong Leaders "Improved efficiency is good for patients, hospital finances, surgeons, and any other physicians," says Litvak. "The only group it is not good for is leaders who do not have the necessary leadership skills or commitment to do what is necessary."
While it's easy for hospital leaders to talk the talk about improved efficiency, it isn't quite as easy to put into practice. Getting back to the scheduled surgeries example, there is a fear, says Litvak, that medical staff will leave the organization, or physicians who have admitting privileges at multiple facilities will admit their patients elsewhere if they can't schedule surgeries at the time they want them—or perpetuate other equally inefficient practices.
The way to deal with this is to be firm, suggests Litvak. "If you're a real healthcare leader, [you] would talk to this [physician] and tell them why [their current scheduling practices are unacceptable]…. If [you] are not a real leader, [you] will bow to physician's demand," he says.
HR can help create and maintain strong leadership by backing up leaders who take a stand for the greater good of the hospital's staff and patients and by spreading the word about the benefits of improved efficiency.
Make sure the offenders know that they're slowing everyone down through their inefficient scheduling practices. It's possible they are simply unaware as to why proper timing of surgeries—and other efficient practices—matter.
3. Promote a Culture of Efficiency Beyond taking a stand for those who push efficiency, make it clear that running your organization in an efficient way is a priority.
While some employees may not initially like this approach, they may change their minds when they realize that efficient policies mean decreased overtime, improved morale, and better employee satisfaction—not to mention an improved patient experience.
Additionally, inefficient practices in hospitals have been shown to decrease quality of care and, in some cases, increase rates of infection, says Litvak. Furthermore, higher rates of infection can negatively affect Medicare reimbursements and quality scores. Armed with this knowledge, you should be able to win over most members of your staff.
"Every clinician wants to do the best for the patient-- They're just not always aware of the solutions," says Litvak.
The Joint Commission has added 125 hospitals to its ranks of Top Performers—hospitals that demonstrate high rates of evidence-based care practices. There is at least one top performer in every state and significant improvement among academic hospitals.
Mark Chassin, MD
President and CEO,
The Joint Commission
Some 1,224 hospitals have earned the distinction of Top Performer on Key Quality Measures in The Joint Commission's annual report, which was released Thursday. This number represents almost 37% of TJC- accredited hospitals, an 11% increase over last year's numbers.
"The release of this report provides the opportunity to gauge progress in healthcare quality improvement, which we've been tracking over the past 12 years of this program," said Mark Chassin, MD, president and CEO of The Joint Commission. "The collective performance of these accredited hospitals on individual accountability measures continues to steadily improve, as it has from the beginning of the program."
There is at least one top performer in every state.
Hospitals that earned the distinction of Top Performer demonstrated an evidence-based care practice at least 95% of time that they had the opportunity to do so.
The data in the report shows overall improvement in the treatment of pneumonia, children's asthma, surgical care, heart failure, and other common conditions. Perinatal care was listed as a quality of care measure for the first time this year, with 180 hospitals voluntarily submitting that benchmark. In future years, hospitals that deliver 1,100 babies yearly will be required to report perinatal quality.
Quality markers that hospitals are still struggling with include antibiotic selection for ICU patients, urinary catheter removal, the pneumonia measures set, and PCI within 90 minutes in heart attack patients.
Academics Catching Up One perennial criticism of The Joint Commission's annual quality report has been the near complete absence of academic or teaching hospitals from the Top Performer list. While the number is still comparatively low, 35 academic hospitals made it to the list this year—up from 24 last year. More than a quarter (29%) of TJC- accredited teaching hospitals made the list—a number which is growing closer to the overall number of 37%.
"I have to say, I always knew they could do it," said Chassin.
Public hospitals are still underrepresented among the list with only 11% of Top Performers specifying government ownership. "I think it has been difficult for some hospitals, particularly those that may be feeling under-resourced, to devote attention to this quality improvement effort than others… It is a challenge for some hospitals to find the resources to do it, but they should be focusing on this and prioritizing it highly, in my opinion," he said.
Some critics of the annual report have claimed that a scoring bias that favors smaller and more rural hospitals. Chassin acknowledges that larger hospitals have more patients to keep track of, but notes that smaller hospitals also have fewer resources. "It's a question of priority setting," he says. "We want to see more resources being devoted to quality and quality improvement, and this recognition program was designed to encourage that kind of priority-setting."
Special Recognition While The Joint Commission only requires hospitals to submit four measure sets of quality of care data of 95% or above to be named a Top Performer, 44 hospitals submitted data for five or more sets of measures, and achieved Top Performer recognition on that expanded set of measures.
A page at the end of the report was dedicated to recognizing these 44 organizations that went beyond the call of duty. "Achieving these criteria is not easy," said Chassin. "For most hospitals, it took many years of hard work."
Of the hospitals that were not named top performers, 718 missed the distinction by only one quality measure and are "on track to receive Top Performer recognition," he said. "Well over half of Joint Commission-accredited hospitals—fully 58%—are top performers this year, or are on track to become one soon."
Louisiana voters have passed two constitutional amendments designed to secure funding for cash-strapped hospitals, but critics say diverting cash to hospitals will hurt other beneficiaries of the state's already strained finances.
In Louisiana, where uninsured patients make up 18% of the population and state budget cuts are frequent, voters have passed two constitutional amendments that provide a safety net of sorts to the state's often troubled hospitals.
In Tuesday's election, two Louisiana Constitutional Amendments were approved by voters, each with a 56% majority. Amendment 1 gives protections to the Louisiana Medical Assistance Trust Fund and sets a compensation rate for nursing homes and other health care providers. Amendment 2 allows hospitals to draw more funding from Medicaid and creates a hospital stabilization fund.
The necessity of establishing such funds is the result of frequent state cuts to Medicaid, says Paul Salles, CEO of the Louisiana Hospital Association. "The cuts that we had received totaled about 26% over a period of several years… Our interest is in protecting services hospitals provide services to those vulnerable [Medicaid and uninsured] patients."
"Beginning in 2009, with the economic downturn, hospitals in Louisiana have been experiencing significant cuts with the Medicaid program and funds availability for Medicaid and uninsured patients. We proposed in the 2013 legislative session… setting up a system which many other states use, a provider assessment program," he says.
"The basis of those programs essentially allows hospitals, in partnership with the state, to pool their funding and utilize those funds under the appropriate criteria that's set up by CMS and the federal government to maintain or attract available federal funding for hospital services within the Medicaid and uninsured realm," Salles says.
The structures within Amendment 1 does not increase taxes or fees; Amendment 2 requires hospitals to pay for assessments, but many hospitals will theoretically receive reimbursements equal or greater to the fees they initially paid. Those reimbursement rates are regulated and protected from decreases by language within the amendment.
A common concern of critics, however, is whether or not hospital patients and their insurers will end up carrying the burden of the assessments, or if funds might somehow be misappropriated. Additionally, no clear plan for implementation of either amendment has been proposed.
Funding Flop The amendments had supporters among voters in both major parties and Salles maintains there was very little organized opposition, but the ballot issues did have some vocal critics. Barry Erwin, president of Council for a Better Louisiana, finds both amendments to be problematic—and questions the ability of the already cash-strapped state to divert funds to healthcare without hurting other beneficiaries of the state's already strained funds.
"The issue [we had with the amendments] was about tying up more dollars in the state constitution," he explains. His organization's leadership has expressed concern over the amount of non-discretionary funds left in the state budget.
"That's a practical problem in our state—the only area left with a sizable amount of money to cut is higher education," Erwin argues. He concedes that healthcare is important and says his organization does not plan to fight or try to repeal either amendment, but adds that leaving the matter up to voters to decide is not a good governing strategy.
Still, he says he understands the motivation behind those, like Salles, who worked hard to create and pass the new laws. "The state speaker of the house challenged the healthcare industry to come up with a solution [to healthcare funding problems]. They worked on this jointly and came up with the amendments. It was a good faith effort, and I don't fault them at all for what they did."
The year before a New Hampshire critical access hospital converted to a renewable fuel oil system, it spent $450,000 on heating oil. It expects to spend less than $275,000 in its first year on the new system.
With winter on the way and energy costs rising, some hospitals are choosing alternative heating fuels and systems to heat and power their facilities.
AtMemorial Hospital in North Conway, NH, a 25-bed critical access hospital on the edge of the White Mountain National forest, leadership found the idea of moving to an alternative energy source especially compelling.
"In the Mount Washington Valley, it's important to have the pollution reduction," says Scott Gage, director of support services at Memorial Hospital. He first introduced the idea of switching to an alternative energy source to his hospital's leadership.
Memorial opted to go with a renewable fuel oil, (RFO) in this case a liquid fuel converted from solid biomass materials—mostly wood—supplied by a sole Canadian manufacturer, Ensyn.
While Gage says there was a mild amount of hesitation about switching to a new and hard-to-supply energy source, Memorial Hospital's leadership was swayed by both the green factor and the cost savings. Ensyn paid the $750,000 it cost to convert Memorial Hospital's standard boiler to a boiler capable of burning RFO says Greg Gosselin, the regional sales manager from Ensyn who worked with Memorial Hospital.
In the year before Memorial Hospital's conversion to RFO, it spent $450,000 on fuel. Gage anticipates spending significantly less than that, $213,000, on RFO during the period between July 2014 and July 2015, plus an additional $50,000 on traditional #4 heating fuel oil for backup.
As a precaution against supply chain interruption, Ensyn installed a "double boiler," capable of switching between the hospital's previous fuel source, #4 heating oil, and RFO. Memorial Hospital keeps between 8,000 and 13,000 gallons of RFO on hand and can easily switch over to burning traditional fuel if needed.
So far, the only kink has been a short-lived maple syrup-like aroma, which was easily remedied by correcting the temperature at which the fuel is burned.
Another New Hampshire CAH, Valley Regional Hospital in Claremont, has decided to make the switch to RFO for similar reasons. "We looked at a variety of proposals including CNG, biomass, and geothermal systems, but for what we were looking for and the infrastructure we had, this project was very economical and will reduce out fuel costs by one-third," says Peter Wright, FACHE, CEO at Valley Regional.
Wright adds that, in rustic New Hampshire, being green is a priority on par with being cost-efficient.
Recoil From Oil "Humanity needs to get off gas," says Chris Lotspech, director, sustainable resources at Celtic Energy, an independent energy engineering consultancy in Glastonbury, CT, which counts multiple hospitals among its clients.
"If you're interested in public health, you shouldn't be undermining it by contributing to climate change more than necessary." Additionally, he says, the prices of traditional fuel oil are likely to increase, making alternative energy a more viable option for healthcare systems.
Hospitals do have unique needs, says Lotspech—in particular, hospitals need an effective backup system, and cannot have any gaps in service. Additionally, hospitals are "relatively energy-intensive facilities," he says.
Lotspech and his colleague, Augustino Dell'Oso, manager of engineering services at Celtic Energy, agree that there are better alternatives than standard heating fuel for hospitals, but that there is no one-size-fits all solution.
"It depends on where you are in the country," said Lotspech. "If you're in Maine or the upper Midwest, you will have access to a lot of wood bioproducts, and they will be cheaper than… if your facility is in the Southwest."
Dell'Oso adds that organizations ought to remember that even biofuel systems may need pollution control devices. "We've seen instances where a local regulatory body will require that [devices] need to be added to the system to alleviate some of the pollutants generated by such things as a [biomass] fuel source."
Liquid biofuels are an emerging and rapidly changing market, and might work well for some organizations that have set up proper distribution channels and are comfortable with taking risks. "Various kinds of biofuels that are sustainably sourced will be good options," says Lotspech, but he makes a point about sustainability: "If you're clear-cutting rain forests in northern Brazil to make a soy plantation, then shipping it to the United States to turn it into fuel oil, that's not very sustainable.
"It's important that you do supply chain management," Lotspech continues. "Look for third-party certification. Know where your fuels come from, particularly if you're going to claim a sustainability benefit…. If you're paying triple to go to biofuels, it might be better to go to a cleaner fuel—maybe natural gas or even compressed gas over oil, and then spend the money you would have spent on fuel on making your facility more fuel efficient."
Strategically Green "Going green" isn't for every hospital or healthcare system. There are definitely ways to save money without making a radical change or adopting an alternate energy source, says Kevin Gombotz, director of commercial energy sources with Envinity, a State College, PA-based engineering group.
In Pennsylvania, where gas has historically been cheap and plentiful, Gombotz tends to stick to what he knows. "There were quite a few biomass projects in PA that were based on more expensive gas. Now that organizations have access to cheap gas, they still have a biomass boiler, but are not utilizing it to the same degree," he says.
"Working within the infrastructure that is already in place, there's a lot I can do a lot with a limited investment," Gombitz says. He suggests creating a five-year strategic energy plan consisting of 20 to 30 small projects that will create savings, then using the savings from those to invest in more ambitious energy projects. "Lead with projects that have a higher return on investment," he suggests.
The most important, and often most overlooked, area where hospitals can save on energy costs is by simply being more efficient, says Gombotz.
He suggests new, more efficient boilers, combing power systems, and projects that focus on making existing equipment work more efficiently. "The improvements made and reconditioning of existing assets can often fund more costly new assets," Gombotz advises.
For both of the New Hampshire hospitals that opted to go biofuel, the choice was clear. The opportunity to cut fuel costs by 30% yearly, the vendor's financial assistance with transitioning to a new boiler system, and the appeal of using a sustainable energy technology, combined to make RFO the most viable choice.
"We might have found something that would save us more money, but it wouldn't have been green," says Wright, whose hospital is slated to complete their transition to RFO by April 2015. "The responsibility for us as one of the biggest employers and leaders in the community to take a stand is one that we welcome."
As baby boomers head into retirement, many healthcare organizations face a leadership crisis. The antidote? Develop your best employees into homegrown leaders.
If your hospital's CEO announced his retirement today, would you be prepared to announce a successor by the end of the week? If you're even the slightest bit hesitant in answering that question, you need to examine your organization's leadership pipeline.
Robust leadership pipelines are the lifeblood of an organization, says Debra Walker, vice president of the healthcare practice group at DDI World International, a talent management consultancy headquartered in Bridgeville, PA.
"There are [health] systems out there where entire executive teams are going to retire in a couple years," she warns. "If everyone leaves at the age they say they're going to leave—[or earlier, they're] going to have a problem."
If you're not sure your organization is prepared, you're not alone. A DDI 2014 Global leadership forecast found that in 2011, only 18% of executives were confident in their leadership pipelines, and by 2014, that number had dropped to 15%.
While it's appealing to consider bringing in new leadership, Walker suggests growing your own. "Your culture might be very, very different, and their leadership style might be very different," warns Walker. "Leaders from outside the organization are often less successful than leaders developed inside the organization."
Great leaders are not born—they are developed over years, given opportunities to learn and supported by their managers, mentors, and colleagues. "Self-driven is a bit of an oxymoron," says Walker. "It takes a village" to groom leaders. Here are three ways your organization can start preparing for its leadership needs now:
1- Identify Potential Diamonds in the Rough Not every person in your organization is cut out for leadership, but a certain percentage might be capable of developing into leaders. While Walker agrees that most people earmarked as candidates are high performers in their current jobs, that's far from the only criteria human resources and upper management should be looking at when considering who to begin developing for leadership.
Walker suggests the following qualities for leadership candidates:
A high tolerance for ambiguity and complexity. "When we promote people up a level, things won't get more simple, just more complex," warns Walker. Anyone moving into higher management needs to have a certain level of comfort with the "gray areas" of business and a grasp of complex systems with many moving parts.
Strong learning orientation. Your candidate must be capable of learning lots of new material in order to do their job—and come up to speed quickly.
Propensity to lead. "You want someone who will bring out the best in people and can step into leadership role naturally," says Walker. Look for candidates people listen to and respect.
Get a balance of values and results. You definitely want someone who lives your organization's values within their roles, but you also need someone who has a history of being results-driven and goal-oriented.
2. Create an Acceleration Pool Once you've identified a small pool of high-potential employees, start putting energy into developing them into qualified leaders—and fast. A talent acceleration pool is a list of designated employees who your organization is making a point of developing for further leadership roles.
Once a candidate is in the pool, seek to accelerate the whole person. Walker suggests a 360-degree evaluation to determine potential weak spots and areas for improvement and further coaching. Areas for improvement can include subject knowledge, leadership training, or seeking to alleviate personal issues like a tendency toward micromanagement or a bad temper.
Walker recalls one physician who needed to learn more about business acumen in order to be properly prepared for a leadership role. As a part of his development, his organization had him negotiate a contract with a health plan. The physician's negotiation was a success, and it was an excellent experience for the candidate.
In addition to keeping your leadership pipeline full, continually developing candidates with high potential will keep your best employees engaged and motivated.
3. Support Your Candidates While developing your candidates, be aware that they will be stretched to the max— a circumstance known as growth tension. It's vital to ensure a culture where the belief in human growth is institutionalized.
Ensure that the candidate is supported through this period and knows that no one expects them to thrive right away—this is a learning experience for them. Also, make sure they have plenty of people around them they can turn to for help.
You will need buy-in from the candidate's current manager. "The manager needs to remove obstacles for the candidate," says Walker. Make sure the manager understands the importance of this development, and that they have the resources they need to allow the candidate time to dedicate to projects that will allow them to grow.
You should also find a mentor or sponsor for the candidate who can help find challenges and activities to help them grow and provide coaching. "Connect them with people with similar passions," suggests Walker. Have a family-practice physician who you see heading for the C-suite? Find another physician who moved on to a business track. A nurse who you see as being a CNO someday? Find another clinician who became a leader for her to learn from.
Keep developing your employees and keep your pipeline full of candidates who will be ready to take the wheel at a moment's notice. You never know when someone will decide today is the day they're going to retire.
If passed, a ballot measure in South Dakota will do away with insurance networks as they currently exist, allowing patients to see any doctor willing to see them.
An initiative on the ballot in South Dakota's next month could be a game changer for healthcare providers, patients, and payers. The measure would end restrictions by insurers as to which providers enrollees may choose through a concept known as "any willing provider."
Mary Milroy, MD
President of the SDSMA
If passed, Initiated Measure 17 would allow any healthcare provider to join an insurance company's network, if the provider agrees to the company's terms and conditions, works within the company's coverage area.
It is supported by a number of medical professional organizationsin the stateincludingtheSouth Dakota State Medical Association. "Patients would not be restricted by their insurance plan as to what provider could take care of them," says Mary Milroy, MD, president of the SDSMA. "[Passage] would allow patients and families to continue to see the doctors and medical providers that they know and trust."
Anyone who has had to switch healthcare providers because of a job change or a benefits change will recall the pressure of having to find a new physician and the effort to bring him up to speed on what may be a complex medical history, says Milroy.
"Sometimes, when you switch around too much, you lose that longitudinal picture of comprehensive care," she says.
Straight and Narrow Networks While narrow networks can offer inexpensive coverage, they aren't always adequate in a state with a small population spread over a large area like South Dakota, says Milroy, reached by phone last week. "I think that this is mainly in reaction to narrow, closed networks."
Given the relatively large size of South Dakota and its sparse population, narrow networks can create a serious obstacle when plan beneficiaries are forced to drive long distances to find in-network providers, says Milroy.
In some cases, patients must take time off from work, drive for hours, and stay in hotels in order to access the medical attention they need.
But Brendan Buck, vice president of communications at America's Health Insurance Plans, disagrees that narrow networks have anything to do with IM 17. "What you have here is a number of specialty hospitals that are not interested in seeing lower prices," he says.
"So, they have started this effort. Were a law like this to pass, it would really benefit just a few doctors and a few hospitals, at the expense of really everybody else. I see where [you could associate this measure with narrow networks], but it isn't really a relevant issue. In this specific instance, that isn't the motive."
Patients who are not happy with provider options under their current plans should look into buying new ones, says Buck.
"Consumers have a wide variety of networks to choose from. There are narrower networks that will provide additional cost savings, but, if a consumer wants a broad network or is looking for a particular provider to be in a network, they have the ability to choose from networks that do have that broader network."
Additionally, he says, few people in South Dakota are likely prepared for the cost increases that AHIP predicts moving to an Any Willing Provider policy will cause.
"Plans negotiate on behalf of consumers for lower prices and higher quality doctors for their enrollees. If you put in place a law like the one proposed, it's going to lead to higher prices, which will ultimately lead to higher premiums and lower quality doctors. It's been estimated that the premium increase will be as much as $5,000 over a decade for one South Dakota family."
He also expresses concerns over the quality of physicians if payers are not able to decide who will be in their networks. "We think [this law is] the opposite of what people are looking for."
Conditions for Competition Milroy insists consumers will not see increased prices as a result of fewer provider networks. "I think that has been [the opposition's] main claim… but we have looked and researched, and we do not see any credible evidence to indicate that."
She points to the 11 states that already have Any Willing Provider laws on the books that have not seen increases in premiums, and to South Dakota's existing Any Willing Pharmacy law. While insurers feared drug prices and copays would increase as a result of allowing patients to go to any pharmacy they wanted, drug prices did not rise, she says.
"On the contrary, what we have seen is an increased competition… we did not see the cost increase that was threatened…. We predict that the same thing will happen [with an Any Willing Provider law]. We disagree with them, and say, 'where's your evidence?'"
South Dakota voters will decide for themselves on the initiated measure on November 4. In the meantime, Milroy says she will continue working for the initiative until Election Day. "I think voters should ask themselves, as a patient, don't you want to be the one choosing your provider, or do you want your insurance company to do it?"
The cost of covering non-eligible "dependents" under an organization's health plan is significant, but avoidable. One health system shares its strategies for fraud-proofing its benefits system, humanely.
Pop quiz: Are the dependents on your employees' insurance policies truly eligible for health insurance coverage under your organizations' plan?
If you think that's a hard question, here's a tougher one: What exactly is a "dependent?"
Before you answer "yes," think again. "On average, 5%–8% of [dependents]are found to be ineligible [during a dependent audit]," says Mike Daugherty, director of corporate benefits at Baptist Health, an 18-facility healthcare system based KY, including seven acute care hospitals and about 16,000 employees.
At an estimated cost savings of $3,500 per covered life yearly, the cost is not insignificant. And it will only rise in lockstep with climbing healthcare costs.
In a dependent audit, beneficiaries are required to submit documentation verifying the eligibility of their dependents. In the case of Baptist Health, the lack of verification became evident after a nurse told some of her coworkers that she'd covered her boyfriend's children on the health system's insurance plan for the last few years. Her colleagues eventually decided that her actions were inappropriate and reported her to HR.
While many organizations would simply have terminated the employee and forgotten about the situation, Daugherty and his team decided to use it as a learning experience. If this case of fraud had managed to get through, they reasoned, it was likely that there were more dependents on the insurance plan that shouldn't be.
The team began to audit the eligibility of every dependent on the plan, with the goal of a more compliant, efficient, and fraud-proof benefits system. Baptist Health shared with me three lessons learned along the way:
1. You Will Find Ineligibles, and Cost Savings
As a result of running a dependent audit, Baptist Health found that 9% percent (or 1,446) of the dependents on its insurance were ineligible. This translated as an annual savings of $3,486,000. "We thought [the protections] we had in place would… keep our dependent data clean. But this wasn't sufficient to catch what you would with a dependent audit," says Daugherty.
The biggest shock of the entire process was in just how money his organization saved through this initiative. "The ROI was pretty amazing. We didn't expect that," he says.
2. Non-eligibles May Not be Obvious Let's say a 10-year old child was abandoned by his birth parents as a baby and has lived with his grandmother ever since. The issue was kept within the family and never went to court, with all decisions regarding responsibility to that child being made informally, between family members. The child a dependent of his grandmother, right?
Wrong, not unless there's a court order assigning the grandmother guardianship or custody of the child. These were the types of sensitive issues that came up during the audit. Stepchildren, foreign-born spouses without translated documentation of marriage and children being cared for by aunts, uncles, older siblings or other relatives all needed to submit documentation to prove they were eligible for coverage.
Baptist Health hired a vendor to assist these employees with finding the right documentation, and to advise them on what steps had to be taken to bring the dependent back under eligibility. The important step, however, is to clearly define what a dependent is, and stick to that definition.
3. Give Fair Warning Warn employees upfront that you will be performing an audit, and their responses might be surprisingly cooperative, says Daugherty. "We experienced 264 voluntary terminations of insurance [by employees who knew their "dependents" didn't qualify]," he says. These terminations alone realized an annual cost savings of $924,000.
Additionally, the organization gave employees three months to respond after the initial announcement of the audit, so they had time to gather proper documentation, birth certificates, court documents, and so on. "It was really important to tell employees up front what we would do," says Daugherty.
Additionally, Baptist Health decided as a corporation that it would not retroactively charge employees if they had claimed someone as a dependent who turned out to be ineligible.
"Employees knew we were looking out for their best interests," says Daugherty. Because employees felt like Baptist Health's leadership was doing this for the right reasons, most of them were honest, responsive, and helpful throughout the process.
Baptist decided to do the same for the nurse whose fraudulent dependents set the process of the audits in motion, electing to keep her as an employee.
A payment plan was set up for her to pay back the cost of the healthcare coverage for her boyfriend's children, and she was briefly put on a performance development plan. More than a year later, she is still employed by Baptist Health.
"I really defended [the decision to keep her as an employee], because I feel we didn't define dependent in a clear way. We looked at our process, and decided we could never have caught this," concludes Daugherty.
Once again, he says, it's important to make sure the definition of a dependent is clear, and that non-dependents cannot fly beneath the radar in the benefits system.
A lawyer shares his top strategies for managing medical doctors. He advises making sure expectations are clear from the start and tells how to protect your hospital or health system when relationships go sour.
A. Robert Fischer
The employed physician trend shows no sign of stopping, with approximately 26% of physicians currently employed within a hospital or healthcare system. This creates new challenges for human resources executives, because these are professionals unaccustomed to being managed—and, in some cases, don't even comprehend what it means to be an employee.
"Lab techs, LPNs, RNs, PNs and so on are used to working under the direction and control of others," says A. Robert Fischer, an attorney for the White Plains, NY-based firm Jackson Lewis, specializes in defending hospitals and healthcare systems against disgruntled physicians formerly employed by them. "Physicians literally make life and death decisions… They feel that they should be given a very wide berth with respect to all matters of their professional lives," he explains.
"Most physicians go to medical school [without] hoping to manage other physicians, or giving it much thought. Nor do they give much thought to being employees on some rung of some ladder in an employment relationship," says Fischer.
Predictably, this culture does not always fit well into the context of an employment situation, and employed physicians are more likely to sue than other healthcare workers when employment doesn't work out. "For healthcare clients…. physician litigation constitutes easily 20% of the [litigations]," says Fischer. Given that only about 8% of healthcare employees are physicians, this is proportionally very large.
A dejected physician will often attempt to say he or she has been discriminated against. "We see discrimination, sexual harassment retaliation, gender, and disability discrimination. These run the range of statutory discrimination claims, with an emphasis on gender and disability," says Fischer.
"But, we see other claims as well," he continues. "Age, issues within the national practitioner database, whistleblower claims—especially in regard to peer review or criticism of another physician's work—breach of contract, contract not renewed for an unlawful reason, certain members of group not treated as well as others, and broader issues, statutory or otherwise."
As the burden of proof is on the employer to show non-discrimination, a thousand questions can run through the minds of HR executives when a potential lawsuit is threatened. Did the physician's managers document their poor performance? Were performance and employment expectations stated clearly? And, what will a jury think?
But, with some planning and strategy, organizations can prepare themselves, says Fischer.
1. Make Sure Physicians Know How to be Employees "It's important to provide some context for what the physician's experience will be like as an employee," says Fischer. While most employees have had some experience being an employee prior to beginning their current career, a remarkable number of physicians went directly from high school to undergrad to med school without any real employment experience.
Fischer suggests setting up an orientation that lays out what the organization's expects of them, including the importance of coming to work on time, what happens during a performance evaluation, what a probationary period means, and so on.
This will make expectations clear to the physician—and is an opportunity to document that a conversation detailing expectations has taken place.
2. Make Sure Docs Expect Feedback Fischer suggests establishing a framework for criticism as something that won't be entirely positive. Let physician know ahead of time when the conversation will take place and what to expect.
"Tell them when and where you will discuss performance and conduct issues. Give some background, especially for younger physicians who are new to holding a job. Get them used to the idea [that] there will be criticism," suggests Fischer.
"It's very useful to then point back to whatever conversation or communication you had previously," he adds. "You can say, 'Remember, we said there would be 180 day probation? It's been 180 days. Now, let's discuss how your probationary period went.'"
3. Offer Objective Criticism It's important to keep criticism objective and fact-based, says Fischer. For instance, if no other physician has had patient satisfaction scores as low as this physician, you can point that out rather than saying "you don't get along with the patients."
Rather than a manager saying, "I feel like it takes too much time for me to manage you," they could say something like, "I'm spending more time dealing with you than all others under my supervision combined." Physicians are more likely to understand criticism if put in those terms, and courts respond well to quantified, objectified statements, too, Fischer points out.
4. Cover Yourself But what happens if, after months of feedback and making your expectations clear, the physician just isn't working out?
"It really goes to setting the groundwork," says Fischer. "While certain behaviors are so dangerous you would terminate without warning, most problems exist for some time." In that case, Fischer says you must tell the physician the severity of the problem. "Say, 'we're not going to continue with this relationship unless this improves.'" Make sure to document that conversation and exactly what was said.
When it comes time to have the tough, painful conversation about discontinuing employment, Fischer suggests harkening back to the original warning. "'Remember, we had a conversation about this two months ago? We said you had to improve to a certain degree? Well, we don't think adequate improvement has been made.'"
Additionally, try impress upon the chief medical officer or others in senior leadership positions the importance of caution in giving a reference or writing recommendations. "That's confusing at best, case destroying at worst," says Fischer, who has seen employment court cases won by the plaintiff based on a glowing recommendation written by a sympathetic CMO.
"One safe thing to do—in the context of resolving any such claims—is to agree upon a reference," he says. Decide during the termination what will be said regarding future recommendations—and have everyone present sign off on it. Of course, simply giving dates of employment and title held may suffice, and is standard practice.
While managing employed physicians is a challenge, making expectations clear and documenting interactions can make things go more smoothly, and will minimize risk in cases where employees must be terminated.
As hospitals tighten the rules around flu vaccinations, a vocal faction of healthcare workers, many of them nurses, is challenging the mandates.
A determined minority of healthcare workers is growing increasingly vocal in its resistance to yearly influenza vaccination requirements imposed by hospitals.
On September 22, the Massachusetts Nurses Association filed a lawsuit against Boston's Brigham and Women's Hospital in Suffolk Superior Court. While this is one of the most prominent cases, the issue has been playing out in hospitalsacross the country.
The matter is complicated because rules about vaccinations are either determined by the states, or not addressed at all. Eight states: CA, IL, ME, MD, MA, NE, OK, and TN have "offer" laws, which are usually interpreted to mean healthcare facilities are required to offer the flu shot must to their employees, but staff have the right to decline vaccination.
Three states—AL, NH and RI—require all healthcare workers to be vaccinated against the flu yearly.
"Are they honestly telling me that… they would rather have patients lose a highly skilled, qualified [unvaccinated clinician]? What kind of incentive would move an institution to impose that as a restrictive policy?" asks Julie Pinkham, Executive Director at the Massachusetts Nurses Association, which represents nurses at Brigham and Women's hospital.
"We've gone along with essentially a voluntary process," she said by phone this week. "We had worked out in previous years that nurses who didn't want to volunteer would just sign a declination form. If a nurse declined for any reason, he or she would wear a mask when entering a patient's room."
"Of course, we're hyper vigilant of the fact that if a nurse is symptomatic, [she or he] shouldn't be in the workplace anyway," Pinkham continued, noting that there are other transmittable illnesses, including colds, for which there are no vaccines.
Unionized facilities have made some headway in protecting their employees from being forced to receive influenza vaccinations "or else," says Pinkham, while non-unionized settings have had less.
"You're an at-will employee. You don't have the same rights as you do under a unionized setting under the National Labor Relations Act or under state law… that's a different mixed bag for what you're going to get for results across the country."
The MNA believes that requiring nurses to get a flu vaccine as a condition of employment is illegal in Massachusetts.
Patients First "Our position is that we always put the needs of the patients we serve first," says Lynn Nicholas, president and CEO of the Massachusetts Hospital Association.
"We really do believe that [flu shots] should be mandated," she continues. "We actually put a bill in to the state legislature that we're going to push [which] actually requires all healthcare workers have a flu vaccine, unless there is a specific religious contraindication or a medical contraindication."
Reached by phone this week, Nicholas said that if passed, the bill would close the legal loophole, cited by the MNA, which maintains that the statewide flu vaccine mandate is illegal.
"People in hospitals today are very ill. Many are immunocompromised, they have multiple conditions, they're having surgery, transplants, [or] they have cancer." Nicholas says.
At the Dana Farber Cancer Institute, where nurses are also represented by MNA, 99% of employees have been vaccinated against the flu. "Those nurses know it would be devastating for their patients to get the flu. And they stepped up to the plate," she says.
Nicholas argues that refusing the flu vaccine for any reason other than on religious or health grounds is antithetical to the very concept of nursing. Pinkham says sick nurses can stay home. But Nicholas points out that people who have the flu are contagious prior to showing symptoms and that nurses are likely to get sick during a flu outbreak—when their presence is most needed at work.
Mandates on Trial Nicholas says she's not heard of flu vaccine resistance for healthcare workers making much progress in the courts, and she has the agreement of Alan Phillips, an attorney in Asheville, NC, who advocates for vaccine exemptions and waivers.
"I think there's been headway made in that court cases sometimes help us clarify the law, but, from the perspective of those who are seeking to avoid vaccines, I think court cases on the whole have been largely ineffective," he says.
Phillips tries to settle his clients' cases, usually by arguing that workplace policies are unlawful. "I don't know that hospitals would [see it this] way, but I'm basically helping hospital administrators to understand the law and helping to bring them into compliance."
Phillips says that the vaccination policies of about 95% of the hospitals that employ his clients are unlawful.
"If it's an unlawful policy, the first thing might be to decide how to address that, if it's… asking you to do something that you can't do as an employee."
Behind the Mask Some hospitals ask non-vaccinated employees to wear masks, but Phillips considers the move punitive. Pinkham disagrees. And Nicholas feels it is a reasonable accommodation for healthcare workers who absolutely cannot or will not get a vaccine.
"I think a patient has a right to know whether someone has used flu vaccine or not, just like they have a right to see whether someone washes their hands when they enter a room… The mask is at least a visible symbol of that. But it would be alarming to patients to see many people wearing masks. It should be the exception, not a rule," Nicholas said.
The CDC estimates that 75% of all healthcare workers were immunized against the flu in over the 2013 – 2014 flu season; the CDC's Healthy People 2020 plan calls for 90% of all healthcare workers receive the flu vaccine yearly.
As part of CMS's plans to improve hospital transparency, vaccination rates of hospital employees will eventually become available to the public on hospitalcompare.gov, beginning December 11, 2014, Don McLeod, press officer at CMS said in an email.
But, as the Massachusetts case works its way through the legal process, Nicholas, notes that for her, flu vaccination isn't just part of a labor disagreement or a goal set by the CDC or CMS. "It's about protecting patients. Getting a flu vaccine is just the right thing to do," she says.