The Supreme Court's decision will impact patients receiving care through Medicare, Medicaid, and CHIP.
The United States Supreme Court recently overturned the long-standing Chevron deference doctrine, which held that courts should defer to agency interpretations of statutes that fall under the particular agency's purview, when the interpretation is reasonable, and the meaning of a statute is not made explicitly clear by Congress.
Hospitals and health systems will now potentially have to wait through legal challenges to regulations that were previously determined by the many federal agencies that influence healthcare.
The 6-3 decision was made on June 28 to reverse the original ruling made in the landmark case Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc., in 1984. It is now up to the courts to determine their own interpretations of ambiguous regulatory standards.
There are many unknowns about how this decision will ultimately play out, but the impact on federal agencies such as the EPA, FDA, and OSHA and their ability to regulate environmental, health, and safety matters is undeniable.
This decision will also potentially impact the healthcare industry in two key ways.
Access to public healthcare
An amicus brief, published in September 2023, warned that "overruling Chevron would have enormous impact on the administration of federal programs, including Medicare, Medicaid, and CHIP, that are critical to public health."
According to the brief, approximately 65 million Americans receive healthcare coverage through Medicare, while Medicaid and CHIP cover 90 million low-income children and adults and seniors with disabilities.
The brief was signed by the American Academy of Pediatrics, American Cancer Society, American Cancer Society Cancer Action Network, ALS Association, American Heart Association, American Lung Association, American Public Health Association, American Thoracic Society, Bazelon Center for Mental Health Law, Campaign for Tobacco-Free Kids, Child Neurology Foundation, Epilepsy Foundation, Muscular Dystrophy Association, National Health Law Program, Physicians for Social Responsibility, The Leukemia & Lymphoma Society, and Truth Initiative.
When Chevron was still in effect, the brief stated, courts deferred to the Centers for Medicare & Medicaid Services (CMS) to make policies that the agency needed to make while "plugging the interstitial gaps that inevitable arise as it administers the health insurance statues in a myriad of every-changing real-world settings."
In a press release published the day of the ruling, the organizations said they were disappointed in the Supreme Court's decision, saying Chevron has helped those organizations ensure that healthcare laws are "interpreted and implemented appropriately."
"We anticipate that today's ruling will cause significant disruption to publicly funded health insurance programs," the contributors said, "to the stability of this country's healthcare and food and drug review systems, and to the health and well-being of the patients and consumers we serve."
The brief’s signees argued in favor of the importance of having experts interpret standards that will have that impact.
"As our amicus brief noted, large health programs such as Medicaid and Medicare, as well as issues related to the Food, Drug and Cosmetic Act, are extremely complex," they said in the press release. "So it is key that decisions about how to interpret and implement relevant laws are made by experts at government agencies."
Healthcare leaders and workers will likely feel the effects of this decision through the impact it will have on public health.
"As leading organizations that work on behalf of people across the country who face serious, acute and chronic illnesses, as well as many people who lack access to quality and affordable healthcare," the signees said, "we will continue to work to ensure that healthcare laws are implemented in ways that benefit the public health."
AWS is providing $10 million in grants to health systems and hospitals for pediatric research using AI and the company’s cloud storage platform.
Three pediatric health systems are receiving $1 million each to support ongoing programs using AI and cloud computing to improve children’s healthcare.
The announcement underscores the hype surrounding AI in healthcare and the efforts by tech companies to partner with health systems for long-term projects that require lots of data storage. Health systems and hospitals are hampered in developing AI programs because of the cost of storing and moving around data, and these partnerships can give them the leeway to improve research and develop new programs.
Adam Resnick, director of CHOP’s Center for Data Driven Discovery in Biomedicine, said AI can be a vital factor in developing treatments for pediatric cancers, which make up less than 1% of all cancers diagnosed annually in the U.S.
“(D)espite being a rare disease, pediatric cancers truly provide a unique proving ground for new technology because of their dependency on real-time discovery and collaborative networks,” he said in the AWS press release announcing the awards.
Research on pediatric diseases and treatments is often limited because of the size of the patient population. Most studies are small-scale and limited, and the pharma industry has little incentive to pursue treatments. In fact, innovation in pediatric care is often based on adult models that are adapted to fit children, with less-than-optimal results.
AWS is banking on its considerable could storage resources to improve what it calls the sandbox in the cloud, giving healthcare providers access to large amounts of de-identified and anonymized data to improve research.
“What’s driving discovery, in the most immediate term, is enabled by the cloud,” Elaine Mardis, PhD, co-executive director of the Steve and Cindy Rasmussen Institute for Genomic Medicine at Nationwide Children’s Abigail Wexner Research Institute, said in the AWS release.
With so many organizations engaged in AI these days, a key question moving forward will be how health systems and hospitals share that information, and which processes are proprietary. That may be where value is determined.
“What we really want to do is make rare cancers less rare by providing this comprehensive information to those who really want to investigate for a variety of discovery-based goals,” Mardis added.
Virtual nursing ROI can be measured in a variety of ways, including sick time, says this nurse leader.
On this episode of HL Shorts, we hear from Clair Lunt, senior director of nursing informatics at Mount Sinai Health System, about using sick time as an ROI metric for virtual nursing. Tune in to hear her insights.
How can CMOs reduce hospital mortality rates at their organizations?
CMOs play a crucial role in helping hospitals reduce mortality rates by overseeing initiatives and strategies aimed at improving patient outcomes, but it’s not as simple as it sounds.
By analyzing mortality data across the healthcare system, CMOs like Andy Anderson, MD, MBA, executive vice president and chief medical and quality office, at RWJBarnabas Health can identify opportunities for improvement and implement tactics to drive change.
In fact, several initiatives at RWJBarnabas Health over the past two years have led to a significant reduction in the hospital mortality rate.
"We recognized a couple of years ago the opportunity to improve our mortality outcomes after doing an analysis of those outcomes across the health system's hospitals," he says. "We saw that we could improve."
One of the strategies RWJBarnabas launched is a mortality review process, which basically means reviewing and learning from a patient's death.
"Each of our hospitals has a team that reviews those cases and identifies whether there are any learning opportunities," Anderson says. "They go back and educate the team that took care of a deceased patient when learning opportunities arise."
The health system can then take those lessons from its 12 hospitals, put them in a single database, and identify common themes, Anderson says.
"For example, we may identify themes in cardiology or neurology cases, then we can go back to the service line and discuss how they can perform better or think differently in the future," he says. "Sometimes, there is nothing to learn from a death, but other times there is something to learn, and we must share that knowledge."
Another mortality reduction initiative has focused on ICU care, Anderson says.
"We are making sure that patients who are on ventilators are getting the right care," he says. "We are making sure that we have appropriate staffing in our ICUs. We are making sure we have enough ICU beds."
RWJBarnabas is heading in the right direction by focusing on the right things, Anderson says.
"We have reduced mortality by 20% across our health system hospitals over the past two years," he says.
The mortality reduction initiatives reflect how RWJBarnabas approaches patient safety and quality in three ways, Anderson says.
"No. 1, we are using data to drive improvement," he says. "We know more clearly how we are doing and the goals we need to achieve. We are monitoring mortality data over time. No. 2, we are working as a health system, sharing best practices, and identifying the best ways to do this work. No. 3, we are using our electronic health record as a driver of change. Examples of using the EHR to address mortality include the deterioration index and the sepsis alert. Epic is helping us standardize best practices."
This article is part of HealthLeaders’ How Do I? series. Read the entire article by Chris Cheney here.
CNOs must protect and support nurses from workplace violence using methods that are tried and true, say these nurse leaders.
Nurses everywhere continue to experience high levels of violence and abuse at work on a regular basis.
In 2023, eight in 10 nurses experienced at least one type of workplace violence, according to a National Nurses United report. While prevention isn't always possible, CNOs need to make sure that nurses are getting support and assistance after workplace violence incidents occur.
Nurse leaders must advocate for using evidence-based approaches to find out what really works and what doesn't.
Prevention
According to Mary Beth Kingston, executive vice president and CNO at Advocate Health, there need to be more studies done to see what prevention methods are actually effective. For example, weapons detection systems might prevent people from bringing weapons in, but they will not mitigate the typical violence that nurses face in the workplace, Kingston explained.
"Look to see what makes sense within your organization," Kingston said, "but also go back and look for the evidence about what does work, and what truly does help keep people safe."
"Make sure staff know about all of the different things that we have to offer for them to support them," Schuetz said, "then make sure that we're assessing the environments [and] making sure we have environmental controls in place that make sense for the location."
To Kingston, prevention involves three key factors:
"I'll focus on the training and practice and preparation, partnering with safety and security, and really assessing the physical environment as well as all aspects of the environment," Kingston said.
Leaders can control environmental factors by making sure that nurses have exits that they can get to at all times, and assessing items in the room that could potentially become weapons in the midst of an incident.
Kingston emphasized that partnerships with safety and security teams, other departments in the health system, and organizations within the community are also critical. Behavioral health response teams can be particularly beneficial.
"When you feel as though a situation is beginning to escalate, you can call for support and have that show of support, as opposed to a show of strength," Kingston said, "a show of support for both the patient and for the nurse at the bedside."
CNOs can also leverage technology for workplace violence prevention.
"With some of the technology that's out there now, you can have a button or some type of alert on your badge, or on some other type of device," Kingston said, "and you can alert folks when you need help, [and] that can prevent an incident from going to injury."
Schuetz added that a zero-tolerance policy for patients behaving aggressively is essential, as well as proper procedures for removing patients when necessary.
"Our facility developed a pretty rigorous process around patient dismissal when they cannot really participate with the team in a way that's conducive for them to get better and it's abusive to our team," Schuetz said.
If patients come through the emergency department, they will still be treated as required, but patients will be discharged and dismissed from the health system if they cannot comply with the patient code of conduct, Schuetz explained.
"A number of these patients will stop coming back to the facility once they have been dismissed because they don't want the hassle," Schuetz said. "It's our hope that they find a facility where they can have a relationship with the team where they can get the care that they need."
Support after incidents
When incidents inevitably do occur, the next steps that CNOs and other nurse leaders take can make a huge difference for the nurse.
Schuetz explained the peer-to-peer support program at her health system, and their new program that involves a team of people that can provide resources to everyone involved in an incident.
"Oftentimes there's collateral damage, people that witness an event are equally as traumatized as the person," Schuetz said.
The program brings leadership, counseling, and chaplain support to the person or people involved to help them recover. Survivors of workplace violence incidents can suffer from PTSD, which can severely impact their careers if they do not receive the proper support and resources.
"We're trying to wrap our arms around those people," Schuetz said, "[by] making sure that they get some time off work if they need it, making sure they know about pressing charges and the support they can have for pressing charges."
Kingston noted that CNOs need to understand that the impact of workplace violence often lasts beyond the incident.
"I think in healthcare we've done a reasonable job of initial follow-up," Kingston said, "but we have to recognize that this can have an impact days after and weeks after."
CNOs should implement a series of responses, according to Kingston, starting with a strong employee assistance program. Organizations should have a formal support process that is not dependent on the individual manager or leader.
It's also important that other types of violence don't go unnoticed.
"If someone's being called a horrific name all day long while they're working, they may not have a strained shoulder or a bruise, but they are also experiencing workplace violence," Kingston said, "and I think we have to recognize the cumulative impact of some of the behaviors we see."
Lateral violence, such as bullying or incivility at work, are also issues that need to be addressed.
"We have to support our frontline leaders to be able to address those types of behaviors," Kingston said. "They're not something that's reported because people don't even recognize that always as another form of workplace violence."
Part one of this piece was published on Monday, June 24, 2024.
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Disruptors are discovering that healthcare can't be run like a shopping center
Another disruptor is exiting the primary care space.
Walmart has announced the sale of its MeMD virtual care program to Fabric, a one-year-old telehealth startup whose healthcare partners include OSF HealthCare, MUSC Health, Highmark, Luminis Health, and Intermountain Health. The move comes just months after the retail giant announced the closing of its virtual care platform and a significant number of its in-store health centers.
MeMD was launched in 2010 and acquired by Walmart in 2021.
Fabric, which offers a multi-faceted virtual care platform for businesses and payers as well as healthcare providers, said the deal would enable it to expand its base and build in-demand behavioral health services. The company secured $60 million in Series A funding in February, with investors including General Catalyst and Salesforce Ventures.
“This acquisition aligns with our strategic vision to transform healthcare delivery through innovative technology and exceptional patient care,” Founder and CEO Aniq Rahman said in a press release. “The combination of our teams, technology, and clinicians strategically positions Fabric to quickly expand across payers, employers, and provider organizations.”
The deal highlights the ongoing challenge of creating a retail primary care model that combines value with sustainability. Many companies are finding that while consumer-facing retail strategies hold promise in improving the healthcare experience, that doesn’t mean a healthcare service can be run like a retail store.
Sanford Health’s remote patient monitoring program in northern Minnesota is giving pregnant women access to critical care services and resources
In rural and remote parts of the country access to care is limited. That’s a double whammy for pregnant women seeking care not only for themselves but for their children.
To Johnna Nynas, MD, OB-GYN, the rural landscape and challenging economy of northern Minnesota offers plenty of challenges for pregnant women in that region. The Sanford Health Bemidji doctor is not only dealing with climate, transportation, and lack of childcare, but also the closure of four labor & delivery clinics over the past five years.
“What we were seeing is fewer patients getting the minimum recommended number of visits or starting their prenatal care very late,” she says. “And there’s not a lot of other hospitals, (so) when patients choose not to come to Sanford for their women’s healthcare, they’re not going to another hospital system. They’re just not getting care, and that’s unacceptable.”
To address those challenges, Nynas helped to launch a remote patient monitoring program that allows Sanford Health care teams to monitor the health of those patients and gives those women access to local and state resources through a network of programs. The project is funded by a 2021 $3.67 million U.S. Department of Health and Human Services Rural Maternity and Obstetric Management Strategies (RMOMS) grant.
It also caught the eye of CNN, which recently named Nynas one of its Champions for Change.
Health systems and hospitals are embracing RPM and telehealth as a crucial strategy to connect with underserved populations. Residents of rural and remote areas, especially those in minority populations, often face a high risk of adverse health outcomes and elevated chronic care concerns. Through smartphones and connected devices, care teams can reach them on demand in their homes or communities, managing care and providing support.
“They can get their care from wherever they are,” says Nynas, whose coverage area includes three Native American reservations in a county whose population is 23% Native American.
A Multi-Layered Outreach
The program launched by Nynas through Sanford Health is multi-tiered, beginning with a communications platform that enables the health system to connect with patients at home and arrange rides to care appointments when necessary. It has also launched a connected care network with local and community physicians and clinics, equipping them with virtual care technology to facilitate telehealth visits when the women can’t make it to their in-person appointments or need an urgent virtual care visit. Those outlying clinics also act as hubs, enabling patients to use wi-fi services they might not be able to access at home, link up with specialists for virtual appointments and even download and send digital health data to their care teams.
Lastly, patients who agree to participate are sent home with a blood pressure monitor and fetal heartbeat monitor and are asked to have a weight scale handy. This enables Nynas and her team to monitor those patients daily, jumping in quickly if anything seems out of the ordinary or needs a closer look.
Nynas says the RPM platform gives her an opportunity to see a different side of her patients than she sees in the exam room.
“If I see a patient who looks polished – she’s showered, she’s dressed nicely, she looks well – in the clinic, I’m missing that … maybe there’s some really big struggles at home,” she says. “Maybe there’s a lot of stressors at home. Maybe she’s very depressed, and when I see that patient in her own environment, I get a better idea of how things are going for her and who she is. And that helps me be a better provider.”
The platform also encourages patients to be more engaged in their health. Nynas says the program is set up to educate patients about “red flag symptoms,” so they might identify those symptoms on their own; at the same time, they’re spreading the word with friends and family.
That community connection is important. A critical element of Nynas’ program is the collaboration between Sanford Health and other resources.
“We were really strategic,” she says, in joining forces with public health and Medicaid programs, non-profits, and other healthcare services. “We learned a lot about what each other does.”
A Lifeline for Women in Need of Help
The program can be a lifeline—literally—for high-risk mothers-to-be. Nynas says all patients are screened at the onset of the program and connected with a high-risk care coordinator to help them access additional services, including ride services, nutrition counselors and other resources addressing SDOH. That initial screening alone, she says, helped the health system boost referrals by 600%.
The health system also used some of the grant funding to add a home health nurse to help with screenings, education, and other tasks associated with a home visit. Nynas says the program’s 2023 goal was to arrange home healthcare visits for 40 pregnant women; they ended up connecting with more than 350 people.
And while the program creates a network of care for women during their pregnancy, that network continues past the baby’s birth. Nynas notes that many maternal health programs seem to forget about the mom at a crucial time: Right after the baby is born.
“It’s kind of crazy to think that, when you have a baby, the baby has a visit in 24 or 48 hours after discharge, and then one week, and then two weeks, and six weeks, and so on and so forth,” she says. With the mothers, meanwhile, “we see them at six to eight weeks [for] one time, and that seems not in keeping with the spirit of what we should be doing as healthcare providers.”
Nynas mixes in stories of success amid the challenges. She references one former patient who was homeless and dealing with substance abuse when she was pregnant, and has since completed a treatment program and will soon have a home for herself and her children.
That said, the challenges are daunting. Providing medical care and support is the easy part, Nynas says. The hard part is “paperwork and firewalls”: Appealing to payers for any sort of coverage they can provide, and working with the Indian Health Service and other federal and state agencies to make sure all the boxes are checked and requirements fulfilled.
And then there’s the HHS grant, which is due to run out soon.
“Those of us in the collaborative, we meet in-person quarterly to talk about what’s next over the next three months, what are our goals over the next six months,” Nynas says. “At our last quarterly meeting it became really abundantly clear that people are anxious about the grant ending and what’s going to happen to our collaborative. When that was brought up [and we said] do you think we should keep meeting, there was a unanimous ‘yes.’ “
“There was a value to us continuing to work together, whether it was funded or not,” Nynas says, “because it was the right thing to do for the women and the right thing to do for our communities.”
Previous telemedicine processes are now helping this health system implement virtual nursing, says this nurse leader.
While virtual nursing programs are new to several health systems, the concept of telemedicine is not.
Kay Burke, chief nursing informatics officer at UCSF Health, shared the four areas where their virtual nursing program is having an impact, and how the health system has built off their telemedicine model to improve virtual nursing workflows.
Burke is a part of the HealthLeaders Virtual Nursing Mastermind program, in which several health systems are discussing the ins and outs of their virtual nursing programs and their goals for implementing this new strategy.
Areas of focus
According to Burke, there are four key areas where UCSF is implementing their virtual bedside virtual care program. The first pilot was completed on one adult inpatient acute care services unit. The next will be in the birth center.
"[We are] kicking off a pilot in which we are virtually proactively educating patients who are scheduled for a C-section," Burke said. "So that's an exciting use case that we're exploring."
UCSF is also expanding the program to additional adult care units and into the pediatric space.
"We are dipping our toe into the pediatric space," Burke said, "exploring one unit that is focused on the assessment of our social drivers of health."
Starting with telemedicine
Virtual nursing is not entirely uncharted territory, Burke explained.
"While the program as launched last year is targeting several inpatient units," Burke said, "we've really been doing telesitting and nurse triage via telemedicine capabilities, eICU, [and] virtual consultation for years."
According to Burke, the COVID-19 pandemic opened the door for many virtual capabilities.
"I want to always sort of demystify that this is brand new." Burke said, "And while the care model is becoming more and more well-defined, there are so many different use cases and instances of virtual nursing that have been in the clinical care setting for many, many years."
Burke explained that UCSF modified the EHR using data that was already in their production system to create a queue or work list for the virtual nurse to work off of, so that the nurse understands which patients are eligible for a virtual nurse.
One example of an eligibility criteria is that all of a patient's discharge requirements have been met. For instance, a patient could have an order to go home, a ride set up, and their medications already set up in their DNE, but they haven't had their patient education completed.
"We know that the discharge education now, through the electronic health record, signals as outstanding," Burke said, "so that falls to the work of the virtual nurse."
UCSF also configured their clinical communication platform by doing a directory design, so that the virtual nurse and the directory nurse can communicate.
"Sometimes even though there is an outstanding task that needs to be completed, the patient is not willing to connect with a virtual nurse or is just not available or ready to do so." Burke said, "So that communication configuration was also something that we need to figure out."
The last step was incorporating the technology. Burke said they already had iPads in the clinical setting as a result of the pandemic, which enabled virtual medical interpretation, visitation, and consultation.
"We just leveraged those to additionally carry out the patient-nurse interaction via video," Burke said, "and the telemedicine capability that we had in place already."
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In this week's episode of the HealthLeaders Podcast, recently retired Banner Health CEO Peter Fine joins CEO editor Jay Asser to share his perspective on how the top role at a health system has changed over time, what it takes to be a successful CEO in the current day and age, and how the industry as a whole has shifted over the years.
