The images of destruction and devastation in Japan are horrific, the human toll incalculable. It's natural to look on from afar and wonder, "Could it happen here?"
The drama unfolding at the Fukushima nuclear energy plant is unprecedented. Rocked by earthquakes and flooded by tsunami just days ago, the reactors have since been jolted by a series explosions and fires. Radiation levels are fluctuating and there is great fear and uncertainty about whether and how the radiation can be contained.
Certainly there are regions of the U.S. that are vulnerable to earthquakes and tsunamis. And for even more of us, there is the real possibility of a nuclear crisis. There are, after all, 104 nuclear power reactors in the United States. Tornadoes and hurricanes are perhaps more familiar agents of devastation. They've damaged and destroyed innumerable lives in communities all around us.
A nuclear crisis could happen here, too, of course, but most states are "poorly prepared" to respond to a major radiation emergency like the nuclear disaster that Japan faces now, according to a survey of state health departments posted this week. How poorly? The accompanying report, published in Disaster Medicine and Public Health Preparedness, concludes that 45% of the states surveyed have no comprehensive response plans for a nuclear disaster. One of the reports in the prescient March issue of DMPHP is on the role of preparedness in communities: "Within the all-hazards spectrum, radiological incidents presenta uniquely challenging array of scenarios for local governmentemergency planning and response."
Another is on the allocation of resources after a nuclear detonation. It doesn't mince words: "Although the chance ofa nuclear detonation is thought to be small, the consequencesare potentially catastrophic, so planning for an effective medicalresponse is necessary, albeit complex."
Challenging. Unique. Complex. And those are just descriptors culled from the abstracts of two reports.
Community and rural hospitals that may be short on specialized emergency preparedness skills now have a place to turn for guidance. It's the Hospital Preparedness Exercises Atlas of Resources and Tools, published by the Agency for Healthcare Research and Quality for the Department of Health and Human Services. This is the first federally funded guide to hospital emergency preparedness procedures.
The Atlas is designed to help hospital leaders identify the resources to develop, evaluate, and improve disaster preparedness exercises.
A companion to the Atlas is the Hospital Preparedness Exercises Guidebook; which points to resources and tools that may prepare hospital leaders for disasters; “however, it should not be used as a sole reference for preparedness exercises,” HHS noted when the Guidebook was published in December.
Your hospital may never need to operate in response to a disaster, nuclear or otherwise. But knowing where to find the resources to prepare for the worst is among the best assets a hospital leader can have.
AHRQ's Hospital Preparedness Exercises Atlas of Resources and Tools may be downloaded here.
Deep within the Patient Protection and Affordable Care Act there is a mandate that extends the Centers for Medicare & Medicaid Services' Rural Community Hospital Demonstration Program for an additional five years beyond its 2010 expiration date. The objective of the program is to increase the capability of the selected rural hospitals to meet the needs of their service areas.
And while being selected to participate in the federal program is seen as a boon to the bottom line, its real rewards may not come entirely in the form of direct reimbursements, nor may they come immediately. Let's take a look.
This week we learn that four hospitals in Maine have been selected to participate in the demo. They are: Inland Hospital in Waterville, Maine Coast Memorial Hospital in Ellsworth, Miles Memorial Hospital in Damariscotta, and Franklin Memorial Hospital in Farmington.
CMS reports that since the program began in 2004, all hospitals participating during the first two years benefitted financially, albeit within a wide range of variation. I don't like to be the ant at the picnic, but a couple of the observations from the first years of the project come as no surprise:
Problems with physician recruitment and retention were ubiquitous. On-call rotations for hospital inpatient coverage were especially challenging.
Expenses related to capital improvements and major equipment purchases pose a continuing challenge for all demonstration hospitals.
In other words, the problems that vex small, rural hospitals remain, despite the more generous federal reimbursements.
Still, FMH's CEO was understandably pleased that her hospital was among those chosen for the demo. "Participation in this program allows us to receive cost-based reimbursement for inpatient services that will provide additional Medicare reimbursement to FMH annually for five years,” said Rebecca Ryder, FMH president/CEO in a statement. “This is a key bridge strategy for our organization as we make the transition from fee-for-service care to the new health care world of managing population health and will allow us to focus on initiatives to improve efficiencies and clinical outcomes.”
And her assessment of what participation in the demo means to her hospital is dead on. She's not crowing about the chance to cash in on hefty reimbursements (though in the first two years of the program they ranged from less than 10% to over 75% above the inpatient prospective payment system).
Instead, Ryder is taking the long view. Program participation (and the financial rewards that come with it) is a vehicle toward a place in the near future that exists beyond fee-for-service care. There, clinical outcomes matter. Readmissions are to be avoided. Patient satisfaction will be tied directly to reimbursements. These are value-based incentives and they will be used to generate FY 2013 DRG payments.
As my colleague Cheryl Clark wrote regarding CMS’s value-based payment plans, "The regulations will apply to discharges at 3,000 acute care hospitals. All these hospitals will have their funding reduced starting with 1% in fiscal year 2013, rising to 2% by FY 2017, but will have a chance to earn that money back, and perhaps more, under the incentives algorithm."
The four hospitals in Maine shouldn't expect to see their financial worries melt away. But they should expect to be better positioned to operate under the coming post-fee-for-service "incentives" as a result of participating in the CMS Rural Community Hospital Demonstration Program.
What's keeping rural hospitals from expanding their health information technology initiatives?
Only 6% of rural healthcare industry executives surveyed recently by HealthLeaders Media said that technology systems/equipment was the top priority on their agendas.
Part of the answer may be found in the same survey, where 45% of respondents said clinical technology is one of the top three cost drivers in their organizations. Despite millions of dollars in government incentives, cost remains a barrier to EHR adoption among many rural hospitals.
"The benefits of health information technology can be especially important for patients and clinicians in small and rural health care facilities, yet these facilities face high hurdles as they look toward joining in the transition to electronic information," Department of Health and Human Services Secretary Kathleen Sebelius said back in September 2010, when HHS had just announced $20 million in funding to be distributed among 1,655 critical access and rural hospitals in 41 states to help convert from paper to electronic health record technology.
There's no arguing with Sebelius on the financials. Rural hospitals aren't known for their deep pockets.
But that's not all that's holding back progress across America's rural and mostly small hospitals. The problem is much more fundamental: Most facilities haven't been designed to overcome their most vexing challenges: short funds and thin staffs.
But now there's an opportunity to re-imagine and re-design the small hospital. What would it look like, ideally?
The question comes from Kaiser Permanente, which is hosting the Small Hospital, Big Idea Competition. It's all about "[using] technology and innovative design to remove barriers to care, increase collaboration among our staff and between clinicians, patients, and their families. [Design ideas] should foster innovation, and create staffing efficiencies that allow us to deliver care to patients effectively and affordably," says Kaiser's competition Web site.
From the physical plant to what Kaiser calls the "total health environment," to the technology that helps staff improve on quality and patient satisfaction while keeping costs in check, what would it feel like to work there?
Designers, architects, students, engineers, and hospital leaders have a chance to start from scratch and submit their concepts for a hospital to be built "on a mostly flat, 30-acre site in a temperate climate." Who could do a better job than hospital leaders? No one, after all, understands how hospitals work better than the people who run them.
Kaiser will give finalists $750,000 to develop their ideas further. The winner will be eligible to contract with Kaiser on executing a full design.
As for technology taking a leading role in the winning entry: Count on it.
In a curious case of Medicare billing, two California hospitals are reporting highly unusual rates of a Third World nutritional disorder.
The condition, called Kwashiorkor, is familiar to anyone who has seen photos of malnourished children living in impoverished regions of developing countries. Kwashiorkor is a Ghanaian word that means weaning sickness. Caused by insufficient protein in the diet, its chief physical manifestations are a distended belly, altered hair color and texture, and muscle wasting.
Kwashiorkor is rare in developed countries, to say the least. Yet a California Watch article appearing in SFGate reports that "in 2009, Shasta Regional Medical Center in Redding reported that 16.1 percent of its Medicare patients 65 and older suffered from kwashiorkor, according to a California Watch analysis of state health data. That's about 70 times the state average of 0.23 percent." Is there an alarmingly high incidence of malnutrition among Medicare recipients in California health facilities operated by Prime Healthcare Services? Or is something else going on? Prime's director of reimbursement management told California Watch that, "Prime Healthcare hospitals cannot, have not, and will not engage in 'upcoding' or Medicare fraud."
For now, at least, there are more questions than answers. But something is clearly rotten in healthcare. In the just-released HealthLeaders Media Industry Survey 2011, just 24% of health plan leaders polled said the industry is on the right track - - that's only one in four, a sure sign of trouble.
More encouraging data from the survey shows that nearly half (44%) of survey respondents said their organizations will be part of an accountable care organization within the next five years. More specifically, reimbursement ranks in the top three priorities for these executives over the next three years.
As we await federal guidelines on ACOs, let's not forget what's behind the coming changes. Bundled payments will be among the most significant changes to come, of course. But let's remember that the 'A' in ACO is for 'accountable,' as in, we stand by this diagnosis, this care plan, these billing codes.
Does having more hospitals drive up utilization and healthcare costs?
New Hampshire Governor John Lynch thinks so. He recently called for moratorium on hospital construction, though in the Granite state only the legislature can order such a move and make it stick.
"We are overbuilding, and if we want to control healthcare costs, we need a comprehensive review to determine what our state's healthcare facility needs are," Lynch was quoted in the Boston Globe.
That view doesn't jibe with the results of HealthLeaders Media's latest industry survey, where rural healthcare leaders identified the top three cost drivers as (ironically) government laws and mandates, labor costs, and clinical technology. Patient lack of responsibility was fourth. Overutilization of services came in fifth.
And maybe the Governor didn't see the report issued recently by the Illinois Hospital Association, detailing the economic benefits of hospitals in the Prairie State:
"[Hospitals] employ more than a quarter of a million Illinoisans and pay them $14.8 billion in wages and benefits annually. In nearly half of the state’s counties, hospitals are among the top three employers. These include skilled, family-supporting jobs that are critical to surviving and recovering from the economic downturn. These jobs generate another 225,900 jobs."
And did Lynch look at stats on hospital beds per capita? By national standards, New Hampshire is not overbuilt. Based on 2008 data, the state had 2.2 beds per 1000 population, which is below the U.S. average of 2.7 per 1000 and tied for 11th lowest in nation. New Hampshire, like its New England neighbors, is shaking off the remnants of a brutal economic recession and its population is aging, right in line with the rest of the country.
Rural hospitals in particular, deliver an economic boost to communities as a source of decent-paying jobs. The responsible way forward would be to plan for and build hospitals now. The economy will benefit in the long term. Scramble later to deal with a shortage of beds and not only will the costs go up, access to care will go down, and years of good jobs and incomes will be lost.
In Chaska, MN, a free-standing urgent care and emergency department just opened its doors. It is a medical center with24/7 ER, urgent care, and specialty clinics, but there is no hospital. Before Two Twelve Medical Center opened Feb. 1, Chaska's city administrator told the Minneapolis Star, "It was quite a trek to get to a hospital emergency room, either by ambulance or driving."
The city's foresight in planning the facility in partnership with Ridgeview Medical Center—it was five years in the making—underscores some of the differences between the healthcare needs of rural and exurban populations versus city and suburban dwellers.
The idea of a freestanding urgent care and emergency clinic may not be high on the list of urban healthcare leaders, but insight into the priorities of rural healthcare executives offers some context.
In the just-released 2011 HealthLeaders Media Industry Survey, survey participants from several industry sectors answered questions about the Patient Protection Act, accountable care organizations, primary care, relationships with payers, reimbursements, and finances, revealing telling differences among rural and non-rural healthcare leadership goals and concerns.
Some of the highlights:
The top priority for rural leaders over the next three years is quality and patient safety, the second is physician recruitment and retention, and the third is reimbursement. Their non-rural counterparts’ top three priorities are cost reduction, quality/patient safety, and developing an accountable care organization.
Only 28%have positive or very positive assessment of the Patient Protection Act. That's compared to 38% of their non-rural colleagues.
Survey respondents place a high value on nursing, with 74% reporting that the CNO is part of their senior executive team, compared to 58% of non-rural leaders. Not surprisingly, 29% say the nurse supply will have a strongly negative impact on their organizations, compared to 2% of non-rural leaders.
The high impact of nursing staff in rural health systems is clear. And seeing as how patient satisfaction scores will soon be tied to reimbursement, it's no coincidence that leaders want to engage nurses and elevate them into positions of senior management. Nurses are key to boosting patient satisfaction scores.
There's much more to glean from the Industry Survey. Other sectors highlighted include Leadership, Finance, Marketing, Technology, Quality, Physicians, Health Plans, Nurse Leaders, and Service Lines. Click here, to see full results.
National Coordinator for Health Information Technology David Blumenthal, MD, may be a short-timer, but he's not yet finished with his mission to facilitate rural healthcare providers' adoption of electronic record systems. Blumenthal, who announced last week that he will step down this spring to return to Harvard Medical School, is not coasting to the end of his term.
This week he took exception to a study published recently in the Archives of Internal Medicine that concluded that the use of an electronic health record system does not significantly improve the quality of patient care. The study data, he suggested, was flawed.
Since being appointed to his post by president Obama in 2009, Blumenthal has been an energetic advocate for EHRs. In an interview with HealthLeaders Media last year, Blumenthal articulated his vision for EHRs: "We envision a future where information follows patients," he said. "Unconstrained by competitive rivalry, unconstrained by geographic boundaries, unconstrained by cultural disinclinations to collaborate. We want teams to emerge in local communities that make exchange possible. And we will be using the meaningful use framework and all other levers at our disposal to try to make that possible."
And the federal HIT chief has not been shy about putting his (employer's) money where his mouth is. On Tuesday, his office announced $12 million in new federal funding to help critical access hospitals and rural hospitals adopt certified health information technology. That brings the total to $32 million since September for the nation's 62 Regional Extension Centers to help more than 100,000 primary care providers identify and share best practices in EHR adoption, meaningful use, and provider support.
These are some of the services most RECs can provide:
Strategic planning
Stakeholder analysis & engagement
Governance planning
Information architecture development
Policy development
Operational planning
Vendor review & contracting
Change management
Project management
The ONC has big shoes to fill when Blumenthal leaves. It may be tough to find as passionate an advocate as the physician-turned-EHR evangelist who kept rural healthcare providers on his radar. Let's hope his successor makes it a priority to speed the implementation of EHR far and wide, so that all Americans may benefit, not only those who live in or near large cities.
The forecast for heart disease in the U.S. is on par with the dire predictions from meteorologists tracking a monster winter system across the Midwest and into New England this week. A destructive force is gaining strength, we are told, and it's headed this way.
Research published in the Jan. 24 issue of Circulation: Journal of the American Heart Association, predicts that the cost of treating heart disease in the United States will triple over the next two decades. A spike in future disease rates is foreseen by researchers as a result of population changes in age and race.
For most of us in the winter storm's path, preparation is straightforward. We lay in ample supplies of milk, bread, and eggs, and hunker down for the duration (and French toast).
For hospitals aiming to profit from rising rates of heart disease, preparation may also seem straightforward. Eyeing a growing wave of patients with occluded arteries, heart attacks, and congestive heart failure, many hospitals seek to extend their cardiac service lines. By building cardiac catheterization labs, the thinking goes, they can treat patients with ST-segment myocardial infarction (STEMI) by offering primary percutaneous coronary intervention (PCI). Compared with fibrinolytic therapy (FT), PCI is better at reducing mortality when administered in a timely fashion.
But because PCI is only available in hospitals with cath labs, FT remains the standard of care in most U.S. hospitals. It would appear that the thing to do is to start building cath labs.
Or is it?
Is that a financially viable approach for regional hospitals? A study originally published in the September issue of Circulation: Cardiovascular Quality and Outcomes set out to determinethe effectiveness of regional strategies for delivering PCI.
The authors of "Comparative Effectiveness of STEMI Regionalization Strategies" suggest that it is not necessarily cost-effective for a regional hospital to have a cath lab, so long as proper strategies for the emergency transport of STEMI patients to PCI-capable hospitals are in place. The study cites data from a separate paper, which found that "80% of the U.S. population lives within a one-hour drive of a PCI facility, but fewer than 80% of eligible patients with STEMI actually receive PCI."
Researchers say that the most cost-effective solution is to devise a two-pronged strategy to enhance PCI access within a region: build capacity using hospital-based strategies, and leverage access by using an emergency medical service strategy.
This risk/benefit analysis applied to the STEMI/PCI question is objective and the study's conclusions are logical. But who will be able to convince hospital CEOs that they should pass up the opportunity to build out a service line in favor of collaborating with other, often competing hospitals and EMS services, to hammer out a logistical plan that may ultimately result in fewer (STEMI) patients coming through the doors? That's a tough sell.
People who live in rural areas have less access to medical care than residents of urban areas, ergo they receive fewer health services, such as surgery, right?
Not so fast. Despite all that's been written about barriers to access and an acute shortage of providers in rural areas, a study published this month in the Archives of Surgery offered a surprising revelation.
The study's authors set out to determine whether Medicare beneficiariesin rural areas were less likely to undergo a variety of surgicalprocedures compared with their urban counterparts. What they concluded was the exact opposite: "Medicare beneficiaries living in rural areaswere more likely to undergo a broad array of surgical procedurescompared with those living in urban areas."
Specifically, researchers from Texas Tech University Health Sciences Center and Southern Illinois University School of Medicine found that compared with urban Medicare beneficiaries, ruralMedicare beneficiaries were more likely to undergo:
carotid endarterectomy (35%)
lumbar spine fusion (32%)
knee replacement (30%)
abdominal aortic aneurysm repair (28%)
prostatectomy (22%)
aorticvalve replacement (18%)
open reduction and internal fixation of the femur (16%)
What's going on here?
Is this population sicker than its urban/suburban/exurban counterparts? Does it need these surgeries at greater rates than its urban/suburban/exurban counterparts? Is there a true medical need for 30% more knee replacement surgeries, or do Medicare reimbursements enter into the "to cut, or not to cut" decision-making process?
The study looked only at Medicare recipients, which usually covers persons age 65 and older, so it's logically sound to presume that this population is sicker. This group might also tend to delay getting care because of limited access to providers and/or other reasons (cost, for example).
Treatment delays, of course, may exacerbate certain conditions, speeding a patient's course toward surgery. So perhaps, the finding was not as surprising as on first glance.
Concerns about poor access to rural healthcare services, and the costs associated with private payers are very real. In remarks published in the Kansas City Star last week, Department of Health and Human Services Secretary Kathleen Sebelius spoke in defense of the Affordable Care Act:
"Families in rural areas are often forced to choose between a few powerful insurance companies. The result is that rural Americans are more likely to be uninsured, have higher out-of-pocket costs, and pay more for their insurance premiums than the rest of the country… By holding insurers accountable, the law frees families in rural communities from the worst abuses of the insurance industry and helps keep premiums down … Yet some in Congress say they want to repeal the law. We can’t afford to let that happen."
One study showing robust rates of surgical services for rural Americans should not be taken at face value. Healthcare services for this group are sorely lacking, but provisions within the ACA are in place to begin boosting both the amount and quality of healthcare. Repeal of the law would be a significant blow to this group.
A study out of Boston finds that one reason MRSA is so stubbornly present in hospitals is because a significant percentage of patients present in the emergency department with the drug-resistant staph infection already onboard.
Five percent may not sound like a significant number, but more than half carried MRSA on multiple sites, according to a study published in the Annals of Emergency Medicine, increasing the likelihood of transmission.
Widely regarded as a deadly superbug responsible for close to 500,000 hospitalizations and 19,000 deaths a year in the United States, MRSA is reportedly in decline. But if it's in your hospital (or on your leg), those are the only data points that count.
The good news is that best practices for infection control don't hinge exclusively on costly or complicated measures that may be out of reach to healthcare facilities without deep pockets.
On the contrary, the first line of defense is handwashing, a simple and inexpensive maneuver too often taken lightly by busy hospital staff. Hand hygiene is remarkably effective at reducing rates of infection transmission, but must be reinforced by hospital leaders. Monetary incentives, marketing campaigns, and the pressure of accountability (sometimes via the use of spies) are all effective tools for nudging handwashing compliance upward.
Also effective is the use of gowns and gloves and isolation of MRSA-positive patients. Hospitals with multi-bed ICUs have been found to have significantly higher incidences of infection, than those with single-bed ICUs, say researchers at McGill University. Hospitals that convert multi-bed units to single-bed private rooms with their own sinks—slashed hospital-acquired infection rates—including MRSA—by half.
The news about MRSA is improving, albeit slowly. University of Rochester Medical Center orthopedic scientists announced this week that they are a step closer to reducing the risk of the deadly bug.
The team discovered an antibody that can stop MRSA bacteria from growing in mice and in cell cultures. It's a long way off from zapping the bacteria on a person's skin, but it's a step in the right direction.
"A vaccine in humans would probably not be a foolproof approach to preventing infection 100%of the time," team leader Edward M. Schwarz, PhD, said in a statement. "However, even if we could reduce the risk of MRSA by 35%, that would be an enormous improvement in the field."
So until a MRSA vaccine is at hand, basic methods of transmission prevention are key. They can and should be reinforced in ambulatory centers, community health clinics, acute care facilities, doctors' offices, and teaching hospitals alike. MRSA is indiscriminate, so healthcare providers must redouble their efforts to stop it cold.
