Like many of his peers, Lowell, MA, physician Richard Ma has repeatedly plunked the listening end of his stethoscope into a latex glove before examining a patient with a suspected communicable disease at Saints Medical Center. But Ma has invented something called the Stethguard, which slides up the scope's neckpiece. The necktie-shaped plastic sheath serves as a barrier and may offer ammunition in the fight to reduce hospital-acquired infection, Ma says.
The American Hospital Association endorsed the Democratic health reform bill as President Barack Obama and leaders in the U.S. House pushed for the bill's passage. Even though hospitals face reductions in payments from the federal Medicare health insurance program for the elderly under the proposed legislation, AMA representatives said the bill will extend coverage to 32 million people who have no medical care coverage. "For hospitals, reform holds the promise of better access to quality care for all," Rich Umbdenstock, president and chief executive officer of AHA, told the Chicago Tribune.
The Stanford University School of Medicine plans to introduce rules that would prohibit its volunteer teaching staff from giving paid speeches drafted by the makers of drugs or medical devices. Stanford already has one of the most comprehensive policies in the country governing the interactions between academic faculty and the medical industry. As of March 22, the 660 community physicians who volunteer their time to teach at Stanford will also have to abide by the same policy that the faculty members do.
Medical staffs across the country have been waiting for more than three years for The Joint Commission to commit to standard MS.01.01.01 (formerly MS.1.20), and the day has finally come. Medical staffs in Joint Commission-accredited hospitals will need to comply with MS.01.01.01 as of March 31, 2011.
MS.01.01.01 has been through several revisions, the first of which, when issued in 2007, sent medical staffs into an uproar. One of the issues that came up for debate was which documents could be included in the medical staff bylaws and which could be kept in supporting documents, such as medical staff policies and procedures.
Medical staffs protested that if every medical staff process was included in the bylaws, the entire medical staff would need to vote on relatively simple decisions, taking up too much time and too many resources.
Many medical staffs also expressed discontent that the 2007 standard allowed the medical staff to bypass the medical executive committee and go straight to the governing board if they felt that the medical executive committee was not adequately representing the medical staff's needs. Some argued that this change undermined the authority of the medical executive committee, whose job is to represent the medical staff to the hospital's governing board.
The draft of the standard that passed this week strikes a balance between what The Joint Commission wants to include in its standard and what the field thinks is reasonable. Many medical staffs were afraid that they would need to extract processes and procedures from their supporting documents and include them in the bylaws to comply with MS.01.01.01. Although it sounds pretty simple, the medical staff would then need to vote each addition into the bylaws, and all it takes is one person to hold up that process.
The way the current standard is written, medical staffs may choose to include the key provisions in a brief summary of, say, their fair hearing processes in the bylaws, but include all of the details in supporting documents, says Ann O'Connell, Esq., with the Sacramento, CA office of Nossaman, LLP. O'Connell has served for the past few years on the MS.01.01.01 task force.
"I think there are a variety of ways to implement the changes. It could range from totally revamping the bylaws and incorporating your extraneous documents into your bylaws, or it could mean that you leave them in separate documents, but summarize the key requirements within your bylaws," says O'Connell.
Also, according to O'Connell, as long as the key requirements are addressed in the bylaws, The Joint Commission staff has assured the task force that it does not intend to micromanage what comprises a "detail" for purposes of implementing the standard.
O'Connell explains that when it comes to the medical staff bypassing the medical executive committee and going straight to the board, The Joint Commission compromised there too. Whereas the 2007 standard allowed the medical staff to directly address the board regarding just about anything, the new standard limits the medical staff to approaching the board regarding amendments to the bylaws, policies and procedures, and rules and regulations only—and it does require the medical staff to present its proposed changes to the MEC first (but MEC approval is not a prerequisite to getting the proposal to the board).
However, this isn't a big change for many hospitals, O'Connell says. "I know many hospitals that have a provision that would allow the medical staff to propose an amendment to the governing board—requiring perhaps a 10% or a 25% petition of the medical staff."
Although some continue to worry that this provision undermines the medical executive committee's authority, "If you don't interpret it too severely, all it says is that we have to have some mechanism to let medical staff members talk to the MEC," says Joseph Cooper, MD, CMSL, a consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.
Hospital leaders may not be concerned whether certain provisions are included in the medical staff bylaws, but they might care about provisions that allow the medical staff to propose amendments to the medical staff bylaws, rules and regulations, and policies and procedures directly to the governing board because the governing board sets the direction for the hospital.
If the medical staff brings an amendment in front of the governing board that would affect credentialing or privileging, for example, the governing board needs to decide whether that amendment would improve or diminish the quality of physicians on the medical staff, and the quality of physicians directly affects the hospital's quality outcomes.
When The Joint Commission sent the most recent version of the standard out for field review in December 2009, it received relatively positive feedback, says O'Connell. Sixty-six percent of respondents indicated that this current standard is an improvement over the past versions and only 4% said it is worse.
The remaining 30% are unsure whether the standard is better or worse and need further clarification. To that end, O'Connell says The Joint Commission will be issuing educational materials in the coming weeks and months.
The political circus that is healthcare reform is entertaining, but distracts our attention from one important fact: Healthcare reform, as proposed in the Senate and House bills and as enacted in Massachusetts, is primarily about increasing access to healthcare insurance, and only incidentally about controlling healthcare costs.
Let us state the obvious. One cannot control healthcare costs without imposing controls of some kind. We know this because we have done it before. In the mid-1990s, managed care plans, through prior approval requirements and the shifting of some cost-of-care risk to providers, significantly reduced increases in health insurance premium costs for a time.
The Clinton administration contributed to this cost control effort with legislation that sharply reduced increases in Medicare spending, although some components of this legislation were subsequently modified or indefinitely delayed. However, this cost-cutting initiative effectively shifted costs to the non-governmental health insurers, as providers negotiated for higher rates from such insurers to make up for lost Medicare revenues. This experiment in healthcare cost control lead to sporadic, sometimes ill-considered, and sometimes subsequently undone, provider consolidations (i.e., hospital to hospital, and hospital to physicians) and a powerful, and ongoing, wave of health insurer consolidations.
The experiment was abandoned in the face of complaints from providers, who didn't have the information systems and other tools to manage the cost-of-care risks that they had agreed to accept, and patients who objected to any restrictions to their access to care (see, for example, the Helen Hunt character's obscenity-laced rant about HMOs in the movie "As Good as it Gets"). Resistance also showed up in opposition to restricted access networks and tiered-pricing arrangements. This brief experiment in cost control, and the reaction to it, created the healthcare financing and delivery system that is now devouring our economy. It led to:
Years of double-digit increases in health insurance premiums (and associated increases in patient co-pays and deductibles, and in the employees' share of premium costs), absorbing most real dollar increases in wages for low and middle income workers;
A significant consolidation in many health insurance markets and some consolidation of provider systems in certain markets; and
A huge increase in the numbers of uninsured Americans, now at 46 million or more.
Overall, our healthcare delivery and financing system, which absorbs 17% or more of our GDP through overtreatment of the insured and undertreatment of the uninsured, produces mediocre outcomes at high cost when compared to the healthcare systems of other industrialized countries (e.g., in a 2008 Commonwealth Fund report, the U.S. ranked last of 19 countries on quality of care measures). As with the recent unpleasantness in the financial services sector, the "invisible hand of the market" (i.e., the rational, self-interested acts of market participants) has produced a financially unsustainable and clinically suboptimal result that is as dangerous to our physical and fiscal health as the other was to our fiscal health alone.
In the 1990s, the prospect, or fear, of healthcare reform was an impetus for a consolidation of providers and health insurers that long outlasted the Clintons' healthcare reform efforts. Today, the specter of Obama Care, has stimulated further provider and insurer consolidation. Like Bill Murray in "Groundhog Day," we are destined to repeat this until we get it right.
In the 1990s, the Clinton Administration's Medicare cost reductions and the non-governmental health insurers' cost control initiatives, to use today's jargon, did "bend the cost curve" significantly for a time. While these cost control efforts were crude, not backed by adequate information systems, and not often linked to appropriate quality, safety and clinical effectiveness, or outcomes, goals, they were nonetheless effective to some extent.
Can we do better this time? The 1990s failure at healthcare reform in general, and cost control in particular, has made us less competitive as a nation, due to rising direct and indirect (for example, lost productivity due to undertreatment of the uninsured) healthcare costs.
Providers and health insurers will continue to consolidate to enable themselves to operate more efficiently in a fee-for-service world. However, some nongovernmental health insurers (e.g., Blue Cross in Massachusetts, with its Alternative Quality Contract) are working with some of these consolidated provider systems (e.g., Atrius Health, Caritas Christi) to create financial incentives for higher quality and more cost-effective care. There are other efforts planned, or under way, by governmental and non-governmental health insurers, to control the cost, and improve the quality, of healthcare services, such as pay-for-performance standards, bundled payments, and capitation.
These are important experiments that could use the resources and economies of scale of large provider systems to transform the delivery, and financing, of healthcare, and, ultimately, to make access to health insurance for the uninsured more affordable. The consolidated provider systems have the capacity, and a wary willingness, to be partners in these efforts.
The federal government could powerfully support these efforts by subsidizing access to healthcare insurance for the poor, and authorizing Medicare and Medicaid payment reform efforts that reward providers based on the quality and cost-effectiveness of care provided to patients. Or the federal government could, as it did in the 1990s, stand aside (other than ultimately imposing draconian, deficit-driven Medicare and Medicaid rate cuts), and let the fee-for-service arms race continue, leading to the continuation of spiraling healthcare costs with no significant improvements in quality or access. We hope for the former, while fearing the latter.
Christopher Jedrey is a partner with the law firm of McDermott, Will & Emery in its Boston office. He may be reached at cjedrey@mwe.com.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
Pushing toward a March 21 vote, House leaders announced a $940 billion health reform compromise that would extend coverage to the vast majority of Americans, cut billions of dollars from Medicare, and impose new taxes on the wealthy and the well-insured. The proposal, a rewrite of a slightly narrower healthcare bill the Senate passed on Christmas Eve, would also significantly expand the federal student loan program. House Democratic leaders hope to approve the Senate bill along with a separate 153-page package of revisions to that bill that House members are demanding, the Washington Post reports.