A study and a related editorial in Wednesday's Journal of the American Medical Association remind us of a fundamental, yet elusive truth of the operating room: two (or more) heads are better than one, especially if they're working together, toward a shared goal.
In the OR it's not the superstar surgeon working as a solo act who has the best outcomes; it's the surgeon who has gathered a staff of strong individuals and led them to act as a finely calibrated team.
But, as an unrelated study puts it: "Sadly, teamwork among the various professionals within the OR is often flawed: Communication is poor, roles are at best ambiguous, and the organizational structure of the team is often unwanted. Furthermore, team members tend to underestimate their individual weaknesses and overestimate their own teamwork abilities and contributions."
These behaviors can lead to medical errors. Among the most common, hemorrhage complicating a procedure, accidental puncture or laceration during a procedure, hematoma complicating a procedure, or mechanical complication of a cardiac device, implant, or graft. But don't expect a shout if something goes wrong in the OR.
The post-9/11 mantra, "if you see something, say something," so familiar to riders of public transportation, is as welcome in the OR as a muddy boot. Says the JAMA editorial: " in many health care sentinel events, a member of the health care team knew something was wrong but either did not speak up or spoke up and was ignored." It's not just in the OR, by the way, that colleagues don't report colleagues. The practice is widespread.
Even though the American Medical Association's code of ethics requires colleagues to report those they suspect are unable to practice medicine safely because of impairment or incompetence, we know that one in three physicians balks at reporting an incompetent or impaired colleague.
And for surgeons in rural hospitals, improving teamwork can be especially challenging. Surgeons at critical access or acute care facilities can be short-staffed and overworked, conditions not conducive to teambuilding drills and exercises, effective though they may be.
A 2009 study, Improved Operating Room Teamwork via SAFETY Prep: A Rural Community Hospital?s Experience, examinedteam-related competencies in a rural setting:
"From July 2006 to February 2007, a prospective evaluation of teamwork among the OR staff working with a single general surgeon in a rural community hospital in Alaska was undertaken before and after the implementation of a preoperative protocol briefing designed to foster team competencies and interactions."
It concludes that team-related competencies may improve OR efficiency and, as a result, could improve patient care and safety. JAMA's wider study, published Wednesday, concludes that participation in a Veterans Health Administration medical team training program is associated with lower surgical mortality.
While it may take a trained village of OR staffers to lower surgical mortality, let it be noted: The villagers need a strong leader.
The National Committee for Quality Assurance recently issued its annual rankings of private health insurance plans for 2010-2011. NCQA evaluated over 300 private health plans and ranked 227 of those based on clinical performance, member satisfaction, and NCQA Accreditation.
At a glance, the results come as no big shock; thetop 20 are chock full of most the usual suspects. But there are a few interesting tidbits to glean from the list:
Harvard Pilgrim came in at #1 for the fifth consecutive year. But in 2000, in the throes of financial difficulties, Harvard Pilgrim entered into receivership for 6 months. The CEO at the time, Charlie Baker, today is a Republican candidate for Massachusetts governor, in what is turning out to be a lively race.
#2 Tufts Health Plan was co-founded by Staples co-founder Tom Stemberg. The office supply retailer said in a recent interview that " [former Massachusetts Governor and presidential candidate] Mitt Romney credits me with having given him the idea of covering every citizen in the state."
Former #5 Geisinger Health Plan CEO Richard Gilfillan, MD, was named Acting Director of the new CMS Innovation Center by CMS Administrator Don Berwick on September 27.
#15 Health Net of Connecticut and its affiliates reached a whopper of a settlement with the state of Connecticut in July over the failure last year to secure the private medical records of 1.5 million policyholders and for the insurers' delay in reporting the breach. Connecticut Attorney General Richard Blumenthal said the settlement imposes a $250,000 fine on the company for HIPAA and HITECH violations.
UnitedHealth Group's first appearance isn't in the top 20. Or the top 50. It squeaks in at #60 as UnitedHealthcare of New England. But it gained 1 million members last month by absorbing the customers of the Principal Financial Group, which left the business.
The detailed report, all 241 pages of it, is here. NCQA drills down in three major areas: consumer satisfaction, prevention, and treatment, and assigns each plan a numeric rank determined by its combined HEDIS, CAHPS and NCQA accreditation standards scores.
NCQA expects to have Medicaid and Medicare plan rankings online by early November and is exploring options to rank preferred provider organizations in 2011. Stay tuned.
October has only just begun, but fears about healthcare reform are multiplying like swooning teens at a vampire flick. The Patient Protection and Affordable Care Act is freighted with anxiety-inducing provisions that are eliciting angst in all quarters. No one, it seems, is spared: not providers, not health plan executives, not employers, and not the public.
At a public meeting in Baltimore Tuesday, officials from the Centers for Medicare & Medicaid Services and the Federal Trade Commission tried to quell the concerns of health insurance executives and healthcare providers over accountable care organizations. Doctors and hospitals worry that by forming partnerships to deliver coordinated quality care to a select group of patients for set fees, they could potentially violate antitrust and anti-fraud laws. Federal officials tried to reassure them:
"From an antitrust perspective, we want to explore whether we can develop safe harbors so doctors, hospitals, and other medical professionals know when they can collaborate and when they cannot," FTC Chairman Jon Leibowitz said in opening remarks at Tuesday's FTC/CMS Workshop on ACOs.
Providers aren't alone in their apprehension. Health plan executives fear that ACOs will only push costs higher. And since no single, agreed upon ACO payment structure yet exists, they may be right.
Here's another provision of the reform law that's sending chills down the spines of employers. It's the so-called medical loss ratio (MLR). Insurers with large group coverage plans are required to spend at least 85% of premiums on medical costs, and at least 80% of premiums for individual and small group plans starting in 2011. If insurers fall short, they will be required to give customers a rebate for the difference starting in 2012.
McDonald's—like some other employers with large numbers of low-wage employees—offers a "limited-benefit" or "mini-med" health plan. Last week McDonald's made headlines for saying that it might cut health insurance to its 30,000 employees. According to the Wall Street Journal, a McDonald's memo to federal regulators said "it would be economically prohibitive for our carrier to continue offering" the mini-med plan unless it got an exemption.
Health and Human Services, stuck between a rock (enforcing the medical loss ratio provision) and a hard place (seeing tens of thousands lose their health insurance, however meager) granted the exemption.
Political agendas aside, the most bone-chilling aspects of the healthcare reform law are the ones that can't be easily pinned down, understood, and applied. Like the lurking possibility of antitrust violations and the MLR, they are ill-defined specters threatening to drain coffers and make zombies out of leaders.
Massachusetts, the first state to adopt near-universal healthcare coverage is out in front of healthcare reform once again. This time, the idea is to revamp the reimbursement system for physicians and hospitals, from the current fee-for service model to a global payments model (aka bundled payments). This is a key step toward adoption of the accountable care organization model, which is getting a lot of attention from both providers and payers, even though it is still loosely defined and largely untested.
State attorney general Martha Coakley's office released a report in January concluding that "the current system of health care payment is not always value-based and health care providers throughout the state are compensated at widely different rates for providing similar quality and complexity of services." The report urged "adopting payment reform measures that account for and do not exacerbate existing market dynamics and distortions."
Fast forward to the present, where Dr. Judy Ann Bigby, secretary of health and human services for Massachusetts heads a working group of state officials and healthcare executives tasked with doing just that. They met this month to begin drafting a payment reform plan.
Some private insurers in the Bay State are already trying out global payments for the care of chronic conditions such as diabetes and high blood pressure. Blue Cross Blue Shield of Massachusetts, which covers three million Mass. residents, has moved 32% of its HMO business to global payments. Tufts Health Plan says that 20% of its business, mostly through its Medicare Advantage program, is contracted on a global payments basis, according to the Boston Business Journal.
How much further these experiments go depends as much on politics as on economics.
The current push for payment reform is being driven by Governor Deval Patrick (D), who is up for re-election in November. His chief opponent, Republican Charlie Baker is no stranger to healthcare. Baker, former CEO of Harvard Pilgrim Health Care, names lack of transparency as the prime suspect in the high cost of medical care. He is viewed as favoring less government oversight than Patrick as a means toward controlling healthcare costs.
Regardless of who wins in November, controlling healthcare costs hinges on three things that must happen more or less simultaneously:
Implementing some form of payment reform
Defining guidelines for ACOs
Negotiating the balance of power among government, providers, & payers
No doubt someone from the governor's office—and someone from the Baker campaign—will be dialed in to theOIG listening session next week on legal issues associated with ACOs.
Whether it's called "healthcare reform" or "Obamacare," the multi-year march toward an overhaul of the nation's healthcare delivery system begins this week. Thoughtful people may agree to disagree on the merits of the Patient Protection and Affordable Care Act signed into law six months ago. But the effects it will have on physicians, hospitals, and payers will be stressful for all. Expect some discomfort.
An in-depth analysis published this month by the Intelligence Division of HealthLeaders Media examines the relationship between physicians and hospitals at a critical moment. Healthcare leaders were surveyed for the report just before the first provisions of the new law were about to take effect, while anticipation and speculation about the reform provisions were in high gear.
Those surveyed had one big number on their minds: 32 million. That's the number of people expected to be newly insured between 2014 and 2016 as a result of Medicaid expansion and federally subsidized insurance coverage through soon-to-be-mandated health exchanges.
Here's where the discomfort sets in. Nearly half of the healthcare leaders surveyed in the HealthLeaders Intelligence Report, Physician Alignment in an Era of Change expect that the increased numbers of insured patients will strain hospital-physician relations. Twenty-two percent said it will have no effect, and 35% said more patients will improve relations. (Why they thought so is a topic for another day.)
"In my view, these differences simply reflect the fact that some see seismic change as a tragedy and others see it as an opportunity," says Craig E. Samitt, MD, lead advisor for the Intelligence Report.
Indeed, one survey respondent noted that "collaboration between hospitals and physicians will be the only way to survive." I would add payers to that pair. Payers—both public and private—are an integral piece of the healthcare system and must be part of any reform-related collaboration.
It's not just the volume of patients that will strain the system. More patients means provider organizations need more physicians, and hospitals and systems are willing to fill the void by employing, acquiring, or contracting as necessary. Over the next 12 to 36 months, 74% of hospital leaders surveyed said they plan to employ a greater number of physicians. Many MDs are already seeking employment, while news of physician groups being acquired is now a regular occurrence.
Change, of course, begets change. Under PPACA, there will be shift away from the fee-for-service model, and providers will be tasked with delivering better care at lower costs. Figuring out how to do that is another pain point, and the work is just getting underway. The patient-centered medical home model and accountable care organizations, may deliver on both fronts, but are largely untested.
Samitt, for one, who is president and CEO of Dean Health System in Madison, Wisc., believes ACOs could facilitate increased collaboration, better patient outcomes, and a better value.
And Paul Keckley, executive director, Deloitte Center for health Solutions wrote in a memo this week: “It’s plausible to believe that alignment of physicians, hospitals and long-term care providers into local integrated delivery systems, a shift from volume to outcomes-based payments and adoption of a national standard of care based on evidence might bend the curve. Time will tell."
Insurers that "unjustifiably" raise premium rates may be deemed ineligible to participate in health insurance exchanges come 2014, says Department of Health and Human Services Secretary Kathleen Sebelius. The insurance industry is an easy target to blame for rising healthcare costs and Sebelius is piling on. Whether she can bend the industry to her will and clamp down on rate hikes remains to be seen.
While the administration is fiddling, the public sees some private health insurers racking up billions in surplus funds, beefing up executive compensation packages, and raising premium rates "unjustifiably" whatever that means, exactly.
In her letter to America's Health Insurance Plans CEO Karen Ignagni last week, Sebelius noted that the Affordable Care Act should result in a minimal impact on premiums for most Americans— about 1% or 2%. Furthermore, she wrote, health costs have stabilized, and employers' premiums for family coverage increased by only 3% in 2010, a figure confirmed by Kaiser Family Foundation 2010 Employer Health Benefits Survey.
The secretary sounded tough: "We will not stand idly by as insurers blame their premium hikes and increased profits on the requirement that they provide consumers with basic protections." But she sounds more like an advocate for an angry rabble than like a force for real change. If she means business, Sebelius will have to back up her words with actions.
She could start by defining what she means by "unjustifiable" rate hikes.
WellPoint, Inc., for example wanted premium pay hikes of as much as 39% on California policyholders last spring, but Sen. Dianne Feinstein (D) called on the company to back down. Days later Wellpoint withdrew its request for the increase, and in August regulators approved a 14% increase. I don't know on what basis 39% was determined to be the right amount. But I am familiar with the tactic of asking for more than you're willing to settle for in order to leave room for negotiation.
I'd like to see some guidance from HHS on what constitutes a justifiable rate increase.
That would be a good place to start.
As for threatening to exclude payers from participating in health insurance exchanges in 2014, I doubt it will have any effect on insurers' behavior today. Payers are no different from providers in that they are mightily challenged to implement systemic changes resulting from healthcare reform legislation. Who knows how high healthcare costs will be by 2014? The government's estimate that a 1% or 2% premium rate increase should be sufficient could be well off the mark.
If Sebelius is serious about keeping down insurance premiums, she's going to need federal legislation that pegs rate hikes to inflation or cost of living increases, or some other marker (unlikely). Or she'll have to enlist the aid of the 25 or so states that don't have the power to regulate insurance premiums, and let them do the heavy lifting. One way or another, she'll have to pull on some levers to get the changes she wants. Tough talk alone isn't going to cut it.
More employers are offering health insurance to their employees, but workers are paying more and getting less than in previous years. That's according to the 2010 Employer Health Benefits Survey, released last week by the Kaiser Family Foundation and the Health Research & Educational Trust. A goal of the Affordable Care Act is to insure 95% of the U.S. population, but the Kaiser report suggests that coverage alone may not necessarily deliver more healthcare.
The number of employers who offered health insurance to their workers went up significantly in the last year, well before the impact of the health reform law was felt.. Surprisingly, the study found, 69% of employers reported offering health benefits this year, markedly higher than the 60% reported last year. It's not clear why this happened, but don't get too excited. The report explains: "The higher offer rate observed for the smallest firms did not produce a large change in the percentage of workers in firms offering benefits because most workers are employed by large firms."
But while more employers are offering coverage, that coverage doesn't go as far as it used to. Since 2005, workers' contributions to premiums have gone up 47%, while overall premiums rose 27%, wages increased 18%, and inflation rose 12%, according to the Kaiser study.
For example, while family health premiums paid by employers increased by 3 % to $13,770 in 2010, the average worker's share of the cost spiked 14%, the Kaiser study finds.
"With the economy struggling, businesses have been shifting more of the costs of health insurance to workers through premiums, deductibles and other cost-sharing," Kaiser President and CEO Drew Altman, Ph.D., said in a statement. "This may be helping to stem the rapid rise in premiums that we saw in the early 2000s, but it also means employer coverage is less comprehensive. From a consumer perspective, the cost of health insurance just keeps going up faster than wages."
According to Kaiser, 30% of employers reported that they "reduced the scope of health benefits or increased cost sharing, and 23% said that they increased the share of the premium a worker has to pay. Among large firms (200 or more workers), 38% reported reducing the scope of benefits or increasing cost sharing, up from 22% in 2009, while 36% reported increasing their workers? premium share, up from 22% in 2009."
Ironically, it may be that "increased cost sharing" in the form of higher copayments and coinsurance costs is discouraging the insured from seeking care.
Physician office visits have been tracking downward for months. Total patient visits to physician offices were down 7.3% in Julyfrom the July 2009—the fourth consecutive month to post negative growth in physician visits, according to researchers with the North American offices of Deutsche Bank Securities.
In the short term this trend may help the healthcare system, which is preparing to comply with healthcare reform legislation and bracing to meet the coming demands of the newly insured as they come online under health care reform legislation. A lighter patient load may give physicians time to implement EHR systems, for example.
In the long term, though, employer-sponsored health plans could be pricing so many out of the market, that the net result will look essentially like what we have today—millions of people unable to afford doctor visits when they are sick. Workers and their employers will be paying health plan premiums. But those workers on employer-sponsored plans, faced with higher out-of-pocket costs, will be no closer to receiving healthcare than they are today.
The Kentucky Supreme Court ruled last week that Medi-Share, a self-described "non-insurance healthcare program based on biblical principles" is indeed a health plan.
Medi-Share, founded in 1993 and based in Melbourne, FL is operated by the non-profit Christian Care Ministry. Medi-Share describes itself as "a program where Christians share each other's medical expenses. Christian Care Ministry and the Medi-Share program are not registered or licensed by any insurance entity, nor are they required to be. CCM does not collect premiums, make promise of payment, or guarantee that your medical bills will be paid. Sharing of medical bills is completely voluntary."
Kentucky sees it differently. "The Medi-Share program "fits comfortably within the statutory definition of an insurance contract because it shifts the risk of payments for medical expenses from the individual to a pool of people paying into the program. Thus, regardless of how Medi-Share defines itself or what disclaimers it includes in its literature, in the final analysis, there is a shifting of risk," Justice Daniel J. Venters wrote for the court. The 5-2 decision is here.
I expect we'll be seeing more of these faith-based alternatives to health insurance as the 2014 deadline for near-universal health coverage nears. The Patient Protection and Affordable Care Act specifically exempts healthcare sharing ministries from the requirement. And that's where things get fuzzy, because it's hard to tell them apart from licensed health plans.
Two other alternatives to health insurance stand a better chance at maintaining their designations as non-insurers.
One of them is Samaritan Ministries of Peoria, IL, which describes itself as "a healthcare needs-sharing organization." SM issued a statement after the Kentucky decision in which its general counsel, Brian Heller, said, “What the court did not explain is how a pooling arrangement can 'shift risk' when all participation in the pool is voluntary and thus no member of the pool has any legal responsibility for any other member’s medical expense."
The Kentucky decision, which likely will be appealed, has no direct effect on Samaritan Ministries members since they do not “pool” their money, but mail it directly to member families in need, the statement explained. That step goes a long way in distinguishing SM as something other than a health plan.
Medi-Share, on the other hand, operates closer to the traditional health payer model. While Medi-Share may not pay providers directly, Christian Care Ministry facilitates the processing of payments. That distinction, of course, was not enough to sway the Kentucky Supreme Court.
Perhaps the court would look more favorably upon the actions of a third player in this space, Christian Healthcare Ministries, "a Bible-based, voluntary medical cost-sharing ministry" out of Barberton, OH. CHM draws a clearer line between itself and insurers. It advises providers that "members are self-pay patients who should receive consideration for assistance programs and bill reductions."
Here's the twist: Some who oppose health reform—and health care coverage—on ideological grounds, and who have sought out these alternative programs precisely because they are NOT health plans, may find themselves members of a program now determined by a court to be... a health plan. It's a real conundrum. These folks are covered by a health plan, but against their will, while many others who desperately want and need coverage can't get it.
Consumer-directed health plans (CDHPs) pay. That's the message this month from the GAO, which released a report chock-full of data to back up the claim. With employer health costs projected to ratchet up 9% next year, an obvious move is for payers to offer CDHPs. The really smart ones will excel at marketing these plans to a narrow and profitable demographic.
The evidence, actually a study of studies, shows that high-deductible health plans with a tax-advantaged account, such as a health reimbursement arrangement (HRA), that enrollees can use to pay for healthcare expenses reduce consumer spending on healthcare.
Businesses are quickly coming to understand the benefits of CDHPs. In fact, 61% of employers said they plan to offer consumer-directed plans in 2011. Employers know that CDHP enrollees are "healthier" than average and that they tend to sip rather than guzzle health services. From the GAO report:
"...of the 21 studies GAO reviewed that assessed the health status of HRA and other CDHP enrollees, 18 found they were healthier than traditional plan enrollees based on utilization of health care services, self-reported health status, or the prevalence of certain diseases or disease indicators."
Here's an overview of the economically pleasing habits of CDHP/HRA enrollees:
Their utilization of services was generally lower than PPO groups.
The HRA groups spent significantly less than the PPO groups.
The HRA groups were generally healthier than the PPO groups. This is in part because the group skewed about 3 years younger, and members were slightly more likely to be male.
Healthcare spending and utilization of health care services for the HRA groups generally increased by a smaller amount or decreased compared with the PPO groups, from the period before to the period after switching.
"Consumer-directed health plans are living up to their expectations as a way to help save employers money and put employees in greater control of their health care. In fact, offering these plans was the most often-cited tactic by employers to control costs. We fully expect that employer interest in CDHPs, and especially full-replacement plans, will continue to increase in the future," said Helen Darling, head of the National Business Group on Health, in a statement.
What the GAO report tells me is that payers who can swiftly market CDHPs/HRAs to younger, healthier, and wealthier populations will be in a position to build loyalty and win market share. Under the Patient Protection and Affordable Care Act (PPACA), however, health insurance exchanges will prohibit payers from selecting applicants on the basis of health.
Plans marketed and sold outside of HIEs presumably remain viable, but the fate of CDHPs under PPACA is an open question.
This summer has been a scorcher for large swaths of the west, south, and east. For healthcare hustlers perpetrating a rash of insurance scams, August's heat has been particularly prickly. The Federal Trade Commission came down hard last week on scammers passing off medical discount plans as health insurance plans. Two dozen states are similarly cracking down.
"These medical discount benefit plans sound appealing because they masquerade as health insurance," said David Vladeck, director of the FTC's Bureau of Consumer Protection. "But they are not insurance. They don't offer the benefits of health insurance, and victims don't know they've been ripped off until after they've tried to use the service and paid their bill."
The FTC action has spurred authorities in other states to move against the bogus plans. There are six related lawsuits in Indiana alone, according to the office of Indiana Attorney General Greg Zoeller.
Last week insurance investigators in Louisiana served cease and desist orders in a phony insurance scam involving a trade association, 13 companies and at least 14 individuals. They fraudulently marketed "medical discount plans" as health insurance plans, authorities said.
And back in February, California regulators blasted an Arizona company that issued discount health plan cards to California consumers, accusing the firm of fraudulently claiming the products being sold were insurance and offering services that didn't exist.
So far, the FTC and law enforcement agencies in 24 states have filed a total of 54 lawsuits and regulatory actions to halt scammers trading in fake health plans.
So-called discount health plan scams are proliferating under near-perfect conditions: economic stress, high unemployment rates, and the regulatory turbulence stemming from healthcare reform legislation. And it's not consumers alone who are being preyed upon. Providers and hospitals are being defrauded.
Medical discount plans are so bad in the eyes of the California Medical Association, that the group has opposed attempts at regulation and licensing.
Sure enough, the matter of regulation was on the agenda at this month's Seattle meeting of the National Association of Insurance Commissioners (NAIC). The group's Antifraud Task Force intends to draft a national standard that discount plans would have to meet to do business and the NAIC plans to "look further into what regulators can do" to address the rash of scams, the group's web site says.
It shouldn't bother. Discount plans prey on poorly informed consumers and create service delays and headaches for busy providers. Only the issuers stand to benefit from these bogus health insurance plans. Regulation would unleash even more misery on hospitals, providers, and consumers.
