When patients leave the ER at Ridgeview Medical Center in Waconia, MN, there aren't a lot of pharmacy options. The closest 24-hour pharmacy is 20 miles away, and many of the patients live in the opposite direction.
But for the most commonly-prescribed medications, patients don't need to leave the hospital, or even see a pharmacist. Instead of driving the 20 miles and waiting for the prescription to be filled in a pharmacy, the patient can receive his or her medication in a couple of minutes.
On their way out they door they can stop at an InstyMeds machine--which resembles an ATM or vending machine--and fill their prescriptions by punching a few buttons.
"We have installed those mainly for patient satisfaction," says Stephanie Svoboda, director of pharmacy for the 110-bed hospital. Ridgeview has installed a similar machine in its same-day surgery center.
Although the national shortage of pharmacists has ebbed, many regions, particularly rural ones, still lack enough pharmacists or pharmacies to meet patient needs. Automated medication-dispensing machines are popping up in hospitals across the country to fill-in for missing pharmacists or to simply make filling a prescription more convenient for hurried patients.
The machines can hold 20-30 different medications, such as pain medications, antibiotics, and other drugs commonly prescribed to ER patients. The pharmacy staff at Ridgeview worked directly with physicians to determine the proper inventory for the machines, which are popular with the ER doctors, says Svoboda.
"Our ER physicians love [the medication dispenser.] They wouldn't give it up for the world," she says.
When a physician writes a prescription, it is synced with the InstyMeds machine. The medications in the machine are pre-packaged based on standard dosing amounts. The patient is given a special code to enter, along with their date of birth, and can pay for the co-pay with either cash or a credit card right at the machine.
Even for hospitals or clinics that don't have to worry about pharmacist shortages, the automated machines can free up pharmacy staff to deal with more complex medications and interact with patients. The ATM-style machines aren't meant to replace a pharmacist and generally don't dispense prescriptions that require regular refills.
InstyMeds, a Minnesota-based company, has roughly 200 machines installed across the country at urgent-care clinics and emergency rooms.
Although interest in automated prescription machines seem to be growing, some states regulate or prohibit their use, which could slow growth.
Ridgeview Medical Center is considering adding a third machine within the next year, says Svoboda.
Late last week the House Energy and Commerce Health Subcommittee took up the issue of pricing transparency in healthcare and heard testimony on three bills that could change the way providers charge patients for services.
Although Democrats vowed to push for more transparency in healthcare, Rep. Frank Pallone (D-N.J.), the health panel's chairman, cautioned against too much transparency based on a report from the Congressional Budget Office that suggested transparency in some markets could lead to higher prices because providers could see what their competitors are charging and attempt to keep up, according to The Hill.
"The concern I guess is about the unintended consequences of too much transparency," Pallone said.
While all three bills would establish baseline requirements for hospitals and other providers to disclose information about how much they charge and how much patients are expected to pay out-of-pocket, where the bills take different approaches is how they are administered (at the state or federal level) and the broadness of their scope.
The following three bills were discussed:
Transparency in All Health Care Pricing Act of 2010 (HR-4700): Introduced by Rep. Steve Kagen (D-WI), the bill calls for hospitals, physicians, nurses, pharmacies, pharmaceutical manufacturers, dentists, and the insurance entities to "publicly disclose, on a continuous basis, all prices for such items, products, services, or procedures." The bill would require disclosure "at the point of purchase, in print, and on the Internet," and would allow the Secretary of Health and Human Services to investigate and fine entities that do not comply.
Health Care Price Transparency Promotion Act of 2009 (HR-2249): This bill also calls for pricing transparency, but it would require all 50 states to develop disclosure requirements without involving the HHS Secretary. The states would have to develop rules related to the disclosure of hospital charges as well as estimated out-of-pocket costs. The bill also calls for the Agency for Healthcare Research and Quality to develop a report on charges and out-of-pocket costs. The bill has both Democratic and Republican co-sponsors.
Patients' Right to Know Act (HR-4803): The broadest and most specific of the three bills (also with bi-partisan support), the Patients' Right to Know Act explicitly includes ambulatory surgical centers in the group of entities required to disclose pricing information. The bill would allow HHS to define some of the specifics, but would rely on states to enact reporting requirements. It also would require health insurers to disclose information about the limitations and restrictions of a health plan, the process for appealing coverage decisions, the amount of cost-sharing required, the number of providers participating in a plan, and more.
None of the three bills emerged as a favorite during the session, and it was unclear at its conclusion when or if the committee would move forward with legislation.
Freezing the current Medicare physician payment rates would cost nearly $276 billion over the next 10 years, which is nearly 33% higher than the previous estimate of $207 billion, according to the Congressional Budget Office.
The cost increase is likely related to an improving economy, which tends to add more to the cost of health services, as well as demographic changes, CongressDaily reports.
Congress has already missed three deadlines in recent months for averting the 21% payment cut mandated by the sustainable growth rate formula. The cost of permanently repealing the formula has been a sticking point in the Senate, and legislators have instead voted to postpone the date of the cut or have had to freeze payments retroactively.
As a new June 1 deadline looms for Congressional action, the revised cost estimates may make a permanent or long-term fix tougher to pass. Earlier this year Congress exempted the SGR fix from new pay-as-you-go requirements, meaning the cost of freezing payments or increasing physician reimbursements would be added to the deficit.
After years of stagnant or declining reimbursement levels, physicians would prefer even a slight increase to 10 more years of frozen payments. However, the CBO estimates that a payment increase tied to the Medicare Economic Index would cost nearly $330 billion over the next decade, and a 2% update through 2020 would cost $374 billion. Both scenarios are unlikely given the high cost.
A cheaper option that has been floated by some is a five-year delay of the SG-mandated cut. That would cost only $88.5 billion through 2015, but physicians would then face a 30% reimbursement reduction and Congress would again have to delay or repeal an even more expensive cut.
A slew of medical associations is trying to keep the pressure on Washington, both through lobbying and an online petition that asks Congress to "please fix Medicare by developing a rational Medicare physician payment system that automatically keeps up with the cost of running a practice and is backed by a fair, stable funding formula."
Although a long-term delay could be viewed as a victory when the alternative is a steep payment cut, physician organizations, including the American Medical Association, are still campaigning aggressively for a permanent replacement for the SGR formula.
"It's well known that the budgetary gimmicks used by Congress to delay Medicare physician payment cuts increase the cost of reform and the size of the cuts, so these new CBO projections are not surprising," says J. James Rohack, MD, president of the AMA. "It's time for Congress to put aside the short-term actions that have more than quadrupled the price of a solution for American taxpayers and fix the problem once and for all for seniors, military families, and their physicians."
Using bar-code technology can substantially reduce transcription and medication errors, and prevent potential adverse events, according to a new study funded by the Agency for Healthcare Research and Quality.
Researchers at Brigham and Women's Hospital in Boston compared error rates in order transcription and medication administration at an academic medical center before and after it implemented a bar-code electronic medication-administration system (eMAR). The eMar system sends electronic alerts when a patient's medication is overdue or if there is a mismatch between the bar codes on a patient's wristband and the medication.
Of the 14,041 medication administrations and 3082 order transcriptions researchers reviewed, they noted 776 errors unrelated to timing on intensive care units that did not use the bar-code eMAR, compared to just 495 on units that had implemented the system--a 41.4% relative reduction in errors.
The rate of potential adverse drug events also fell just over 50%, and the rate of timing errors in medication administration dropped by 27.3%. The authors extrapolated those results to estimate the potential impact on the hospital over the course of a year.
"Because the study hospital administers approximately 5.9 million doses of medications per year, use of the [bar code system] is expected to prevent approximately 95,000 potential adverse drug events at the point of medication administration every year in this hospital," researchers wrote in their report, which was published in the May 6 issue of the New England Journal of Medicine.
In addition, they expect the technology to reduce the number of early or late medication administrations by 270,000 per year and to prevent approximately 50,000 potential adverse drug events related to transcription errors.
The effect of bar-code technology was similar to that of computerized physician-order entry, which can reduce medication errors at the ordering stage by 55%. The authors noted that CPOE is effective in preventing errors resulting from bad judgment or insufficient knowledge, whereas the bar-code system is more likely to prevent errors caused by mental lapses. They recommend using the two in conjunction for maximum effectiveness.
"The two technologies would probably play complementary roles in improving medication safety in acute care hospitals," they wrote.
Vice President Joe Biden and U.S. Health and Human Services Secretary Kathleen Sebelius have awarded $220 million in grants to 15 communities that will pave the way for the nation's ambitious health IT adoption efforts.
The funds were set aside in the American Recovery and Reinvestment Act last year and awarded through the Beacon Community Program, which aims to strengthen the health IT infrastructure in select communities. The lessons learned from these pilot programs will then be incorporated into nationwide strategies for EHR adoption.
"These pioneering communities are going to lead the way in bringing smarter, lower-cost healthcare to all Americans through use of electronic health records. Because of their early efforts, doctors across the country will one day be able to coordinate patient care with the stroke of a key or pull up life-saving health information instantly in an emergency," Biden said.
The funds were included in the ARRA not only to spur EHR adoption, but to also create new jobs. The government estimates that the grants will initially create 1,100 jobs paying an average of $70,000 a year, and that the eventual nationwide health IT infrastructure will someday employ "tens of thousands of Americans."
Recipient communities ranged geographically from Hawaii to Buffalo, NY, and each received between roughly $12 and $16 million for local projects. More than 130 applicants were competing for the 15 awards, and to receive its grant each Beacon Community had to identify "specific and measurable improvement goals" related to the areas of quality, cost-efficiency, and population health.
The goals and measures vary depending on community need. Geisinger Clinic in Danville, PA, plans to enhance care for patients with pulmonary disease and congestive heart failure by creating a community-wide medical home, for instance. The Louisiana Public Health Institute in New Orleans plans to use the funds to reduce racial health disparities and improve smoking cessation rates by linking technically isolated health systems, providers, and hospitals. Using health IT to manage conditions like diabetes and heart disease was a common goal for many of the grant recipients.
Grants were awarded to the following communities:
Community Services Council of Tulsa (Tulsa, OK)
Delta Health Alliance, Inc. (Stoneville, MS)
Eastern Maine Healthcare Systems (Brewer, ME)
Geisinger Clinic (Danville, PA)
HealthInsight (Salt Lake City, UT)
Indiana Health Information Exchange, INC (Indianapolis, IN)
Inland Northwest Health Services (Spokane, WA)
Louisiana Public Health Institute (New Orleans, LA)
Mayo Clinic College of Medicine (Rochester, MN)
Rhode Island Quality Institute (Providence, RI)
Rocky Mountain Health Maintenance Organization (Grand Junction, CO)
Southern Piedmont Community Care Plan, Inc. (Concord, NC)
The Regents of the University of California (San Diego, CA)
University of Hawaii at Hilo (Hilo, HI)
Western New York Clinical Information Exchange, Inc. (Buffalo, NY)
An additional $15 million has been set aside to provide technical assistance to the communities and to evaluate the success of the program.
Supporters of single-payer healthcare rallied in Vermont over the weekend, hoping to maintain momentum after lawmakers passed legislation that could allow the state to experiment with its own universal healthcare system.
Both the state's House and Senate passed similar bills late last month that call for the creation of a commission to look at options for reducing healthcare costs and covering all Vermonters, one of which must be a government-administered and publicly-financed single-payer system. The program would be "decoupled from employment and allow for private insurance coverage only of supplemental health services," according to the Senate bill.
The House version calls for a public-option insurance system and expanding previously-enacted reform efforts in addition to the single-payer experiment. Differences between the two bills still have to be worked out before final passage, and it is unclear whether Republican Gov. Jim Douglas will sign or veto the bill.
If passed, the legislation would make Vermont a laboratory for testing a radically different healthcare financing system. Previous reform efforts--such as the Massachusetts model and the recently-passed national reform--have attempted to expand coverage while retaining the existing private insurance system.
Questions remain, however, about whether the state will be able to implement the single-payer system right away. The legislation calls for the adoption of one final design beginning no later than July 2012, but the plan would first require approval from the federal government. The commission would have to write a proposal to CMS for waiving certain Medicare and Medicaid requirements in order to align with federal health programs.
Douglas has also said he is hesitant about the bills because the new federal healthcare law prevents states from experimenting with their own reform plans until 2017.
In addition to payment system reform, the legislation includes other strategies for reducing healthcare costs and improving quality. The bills call for setting up teams of healthcare professionals to manage patient cases and include goals for reducing annual hospital budgets, for instance.
Except in certain circumstances, systemwide net patient revenue increases for all hospitals reviewed by the healthcare commissioner could not exceed 4% for fiscal years 2011 and 2012, and the commissioner would have the authority to "restrict or disallow specific expenditures, such as new programs."
The Vermont Senate is expected to take a final vote on the legislation later this week.
Employed and insured Americans aren't meeting recommended health behavior guidelines, particularly when it comes to taking advantage of preventive services like immunizations and cancer screenings, according to a new study.
Overall, utilization of preventive services was poor, even among those with access to care. Nearly 74% of insured workers don't get influenza vaccines, and nearly half fail to undergo recommended preventive screenings for colon cancer. Most insured adults aren't following basic healthy lifestyle guidelines, such as eating the recommended amount of fruits and vegetables and getting enough daily exercise.
Researchers looked at the prevalence of healthy behaviors only among insured workers, based on data from nearly 160,000 participants in a Centers for Disease Control and Prevention telephone survey of adults under 65. The findings appear in the May-June issue of the American Journal of Health Promotion.
"Previous research has shown that insured people and employed people are better off than the uninsured, but we wanted to take that out of the equation and ask, 'How are they doing?'" says M. Courtney Hughes, PhD, who led the study with a team of researchers at the University of Washington School of Public Health. "We found they're not OK because they're not meeting recommendations."
The researchers also looked at disparities among the insured. Although health outcome and behavior disparities are well-documented between insured and uninsured populations, they also exist within the population of insured workers. For instance, nearly 35% of insured women in households making less than $15,000 per year forgo recommended breast cancer screenings, compared to only 19.6% in households making greater than $50,000. Similar disparities were seen along race and education lines.
Respondents said cost was a factor in preventing a physician visit more often than not, but it wasn't the only factor. Many of the barriers are related to access and education, says Hughes, who has founded Approach Health, LLC, a health behavior consulting company in San Diego. Employers could improve access with services like onsite screenings and childcare, and taking health literacy into account could reduce the disparities, she adds.
Poor compliance with health guidelines has implications for both policy makers and employers, she says. Companies not only lose money in medical costs when insured employees don't take preventive measures, but they also lose productivity when more complicated medical conditions arise.
And for policy makers interested in expanding access, the results suggest providing insurance alone isn't enough when many of the insured aren't utilizing recommended services. A large number of costly, chronic conditions are tied directly to health behaviors.
"Outcomes are strongly affected directly by these health behaviors," Hughes says. "That's what's driving our healthcare costs."
Nebraska Gov. Dave Heineman told U.S. Secretary of Health and Human Services Kathleen Sebelius in a letter sent this week that his state would not operate a new federal high-risk insurance pool for individuals with pre-existing conditions.
The program was included in the recent healthcare reform legislation and is designed to offer stop-gap coverage to high-risk individuals until 2014, when insurance companies will no longer be allowed to deny coverage based on pre-existing conditions. Nebraska is one of several states that already has a high-risk pool, which serves nearly 5,000 people.
Nebraska residents with pre-existing medical conditions will still be eligible for the federal high-risk pool, which is expected to have lower premiums than the Nebraska Comprehensive Health Insurance Pool. Heineman's decision simply means it will be run by the federal government, rather than contracted by the state government.
Heineman told Sebelius that even though Nebraska had a similar program, a new pool with a different plan design, pricing scheme, and funding requirements were needed, and he had questions about the value of adding a new layer of bureaucracy at the state level to administer the program.
"The proposed level of federal support and premiums will be inadequate to meet all expected obligations of this program," Heineman wrote. "Even with enrollment caps, we are very concerned that funding will not be sufficient to assure a solvent runoff of all claims when the program expires in three years. With so much financial uncertainty, the State of Nebraska cannot afford to subsidize a second high risk insurance program."
Other governors are still weighing similar decisions, and participation in the new high-risk pool may serve as an early litmus test of states' willingness to accept the sweeping new legislation.
Nebraska's Attorney General is one of 20 who has challenged the constitutionality of the new law, a fact that the governor noted in an accompanying letter to state legislators. He also pointed out his own concerns about the bill.
"As you know, most Nebraskans are opposed to this legislation because it will raise taxes, cut Medicare and premiums will continue to increase. I share their concern," Heineman said.
The federal pool is scheduled to kick off in July.
After a year of debate and lobbying and speculation, the passage of the Patient Protection and Affordable Care Act last month seemed like a definitive period at the end of long and rambling sentence. But for the health insurance industry, it might have just been a comma, bringing only a brief pause in the pursuit of industry reforms, rather than its end.
Last week the Senate heard testimony for a new bill introduced by Sen. Dianne Feinstein (D-CA) that would give the Secretary of Health and Human Services the authority to approve or deny rate increases proposed by health insurance companies.
This regulation is typically handled by the states, but nearly half don't require premium reviews, and Feinstein's bill would establish a seven-member advisory board—with at least one medical professional, one health insurer representative, and two consumer advocates—to establish a nationwide "backstop" for premium increases. States could still impose additional regulations of their own on top of the federal minimum.
Feinstein's proposal was briefly included in the original healthcare reform legislation, but was taken out because it didn't meet the requirements for inclusion in the reconciliation process. As is, the law requires insurers to submit premium increases to the feds and publicly disclose reasons for the hikes, but stops short of giving the government authority to reject a rate. Feinstein's bill changes that.
If HHS deems an increase unacceptable, the legislation gives the department authority to deny or modify the rate increase, order rebates to consumers, or take "any other actions that correct the unreasonable increase."
Naturally, health insurers think they've been regulated enough already. Karen Ignagni, president and CEO of America's Health Insurance Plans (AHIP), told the Senate Health, Education, Labor and Pensions (HELP) committee that the industry already has enough requirements to meet in the existing reform law, and argued that premiums have little affect on overall healthcare costs.
But in some ways, insurers gave legislators the ammunition for this attack—or to be specific, Anthem Blue Cross of California, which earlier this year requested a 39% rate increase, may have single-handedly turned the tables on healthcare reform's fate. Feinstein cited similar increases—up to 56% in Michigan, 24% in Connecticut, and 23% in Maine—in support of her bill.
The natural instinct of any industry facing a new regulatory environment is to adapt as much as possible before the changes take effect. We saw many credit card companies changing certain policies while they still could before new consumer protections kicked in this year, for instance.
But health insurers have to tread very carefully with reform still on the Congressional agenda. Every instance of bad press about rate increases, targeted rescissions, and other controversial practice gives Congress new talking points for expanding the scope of reform.
It doesn't stop with rate regulation, either. There is still a stand-alone public option bill floating around, and specifics about how to enforce the new bans on rescissions and denials for pre-existing conditions have yet to be determined.
Politically, these changes may be difficult to pass as mid-term elections approach and Democrats struggle to win even a single Republican vote for their proposals.
Then again, that's exactly what everyone thought in February before Anthem proposed a 39% rate hike.
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When my father started getting sharp, shooting pains in his head and neck last fall, he tried to just tough it out. That's basically how he handles most health problems. It can be a dangerous waiting game to play—the possibility of something serious like cancer or heart disease always looms in my mind—but he has few other options. He doesn't have health insurance.
Luckily, his eventual trip to the emergency room revealed a bad case of shingles and nothing more severe. But with no primary care doctor and no insurance, the emergency room is his only real source of care. Even that he only uses that when absolutely necessary. I remember him seeking medical treatment only a few times in my life, the last being an emergency hernia operation several years ago.
It's not that he doesn't want health insurance. He can't afford it—as a self-employed entrepreneur he was hit early and hard by the downturn. Like millions of Americans, he has had to choose between health insurance and other necessities like food and shelter, and lives one medical emergency away from financial disaster.
Cynicism about healthcare reform comes easy these days, especially after a solid year of hyperbole and bickering. When politicians talk about expanding access to 32 million Americans, most just hear that as another number in a litany of statistics.
But I personally know one of those 32 million whose prospects for real medical care improved with the stroke of President Obama's pen this week, and so does every physician who provides uncompensated care or spends time in an ED.
This is why what happened this week matters and why Vice President Joe Biden emphatically referred to it as a "big . . . deal" (with Biden's own kind of emphasis). Not just because of the opportunities it opens for people like my dad, but also because the next time Denver Health sees him, he will hopefully have better means to pay for care, and even follow-up with primary care physicians and specialists outside of the emergency room.
As long as I have been writing about healthcare, physicians have been sharing with me their frustrations about the number of uninsured in the country. Doctors not only struggle financially because they often provide uncompensated care, but many also are morally uncomfortable with a system that excludes so many people. Expanding access to insurance is important because it will help these patients get the right kind of care, which should be both cheaper and better quality in the long run.
Was the final healthcare reform package all that it could and should have been? Far from it. There is still a lot left undone in the areas of cost and quality, as well as preparing for an influx of newly-insured patients.
But those who aren't simply grinding a political axe will find reasons for optimism even on those fronts. The Medicare payment board opens a path for changing the reimbursement system to reward quality instead of quantity. Several CMS demonstration projects are testing new ways to align hospitals and physicians for better and cheaper care. Investments are being made in HIT, comparative effectiveness research, primary care, and other fundamentals of a strong healthcare system.
Somehow a moderate and incremental piece of legislation emerged from a bitterly partisan political process (in substance, it is essentially a Republican bill passed by Democrats). But it is best to think of it not as the end to healthcare reform, but an important first step. Given the historical struggles to pass reform, more like a giant leap.
Before even knowing who the candidates would be, HealthLeaders editors reserved a spot for the 44th president of the United States in our November 2007 HealthLeaders magazine story about "20 People Who Make Healthcare Better."
"We are holding a spot for a purposeful, studied and impassioned driver of ideas that will change fundamental cracks in healthcare funding and quality," wrote editor Jim Molpus more than three years ago. "We hope this man or woman will understand the inalterable relationship between our future prosperity and our nation's health. We are hopeful our next president understands the urgency."
While some disagree with his approach, few can claim that President Obama doesn't understand the importance of the healthcare system or the urgent need to fix its many problems. Since assuming office he has made healthcare reform his top priority, beginning with incentives in the stimulus package to jump start electronic health record and comparative effectiveness adoption, and continuing with an unprecedented expansion of access.
Hopefully that focus will continue, because the real work is only getting started. And hopefully politics will stop being such an obstacle to solving the real problems that remain. Because contrary to the ugliness of the last year, reforming healthcare ultimately isn't about ideology or which political party wins or loses or getting all or nothing in one fell swoop.
As the best physicians will tell you when asked about the reason they got into medicine, it's about the patients. And for patients like my dad, the legislation passed this week means access to potentially life-altering medical care for the first time in their lives. For millions more, it means pre-existing conditions or losing a job no longer preclude them from the system. And it means over time, uncompensated care will fall down the list of problems that keep physicians up at night.
That really is a big deal.
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