A state-mandated analysis of the plan says it won't drive medical costs for the region. But opponents say expansion won't improve care for area residents.
Opponents of a $1 billion expansion planned at Boston Children's Hospital that would demolish a beloved garden say the proposal "is explicitly designed to serve international and out-of-state patients, with no clear need for its planned services among Massachusetts families."
The group Save the Prouty Garden made the claim after reviewing an analysis of the project. Navigant Group conducted the analysis for Boston Children's, which was mandated by the state's Department of Public Health, to answer questions about the expansion's impact on healthcare in the state.
"Navigant's analysis shows that BCH does not need to expand. It wants to expand, to target more international patients and raise revenue," said Gus Murby, spokesman for Ten Taxpayer Group, which has intervened with DPH to block the expansion.
The 46-page report, however, is mostly favorable toward the expansion and says it would not drive up medical costs for the region.
"The project is consistent with the Commonwealth's efforts to meet the healthcare cost containment goals," the report states, according to The Boston Globe. "The project's short-term and long-term financing are affordable without utilization or pricing changes."
The report marks the latest development in a controversy that has simmered since the project was announced earlier this year.
"We have reached the limits," BCH CEO Sandra L. Fenwick said in February. "Our partners, our patients, and the families and staff lie at the very heart of the plans we brought to you today. To increase our capacity to heal, we must modernize."
The proposed $1 billion expansion calls for an 11-story, 575,000-square-foot addition, which the hospital says will boost the patient experience by eliminating all of double-bed rooms, enhancing privacy, sleeping spaces, and showers.
Opponents sued the hospital in April, alleging that the hospital broke the law when it broke ground on the project before receiving DPH approval. Among several complaints, opponents claimed the hospital, which is one of the most expensive in Massachusetts, is retreating from caring for the poor.
Data is collected by electronic sensors attached to alcohol hand-rub and soap dispensers in patient rooms and hallways at the two hospitals.
At EUHM, an urban teaching hospital in Atlanta, GA, the sensors are located in five adult ICUs and on two other floors. At EJCH, a smaller community hospital in Johns Creek, GA, the monitoring units have been installed in one ICU and on one medical floor.
Healthcare workers participating in the study wear badges equipped with Bluetooth technology to communicate with the sensors, which can detect when badge-wearing study participants are nearby, and can detect whether alcohol or soap has been used.
In addition, sensors in patient rooms use ultrasound to detect if badged or non-badged persons enter or leave the room, and simultaneously monitor for hand hygiene compliance.
In some stages of the study, a voice reminder will sound if a healthcare worker enters a room and doesn't clean his or her hands.
The researchers will compare the efficacy of different types of feedback to employees on how reliably they clean their hands.
"The purpose of this project is to look for cues to remind us what we need to do to make ourselves the best we can be when it comes to hand hygiene," Marcia Postal-Ranney, RN, manager of infection prevention at EJHC, said in a statement.
The Emory study of the relative effectiveness of cues is similar to work being done at the Perelman School of Medicine at the University of Pennsylvania, which is testing ways "nudges" can be used to optimize medical decisions and improve the value of care.
Initially, the units involved in the Emory study will receive reports of overall compliance rates. Other strategies will be used later in the study, including immediate voice feedback on room entry and individual employee compliance for those using the study badges.
Different voice reminders will be tested, as will combinations of feedback methods.
In addition, researchers will survey participants' attitudes and beliefs about hand hygiene, being monitored, and hearing voice reminders.
Emory Healthcare's hand hygiene rates are roughly 60% according to trained anonymous observers, based on only 20 observations logged per month for each unit, according to James Steinberg, MD, co-principal investigator of the study.
In contrast, an automated system could make "tens of thousands" of observations per month, Steinberg said in a statement.
Emory's hand hygiene compliance rate is similar to that reported in a recent study, published in the American Journal of Infection Control. That study determined that staff at 15 New Mexico outpatient care facilities failed to wash their hands 37% of the time.
"Our goal is to determine if providing individual compliance rates and immediate feedback with various voice reminders will produce an increase of hand hygiene more effectively than either intervention alone."
The non-equity partnership will focus on coordinating EHRs and clinically integrated networks, outpatient scheduling, and streamlining access to Emory's quaternary and tertiary services.
Emory Healthcare and Stratus Healthcare on Monday announced plans for a non-equity strategic affiliation.
"Our focus in establishing this innovative partnership is to build strong institution-to-institution affiliations with hospitals and physicians across Georgia," Jonathan S. Lewin, MD, CEO of Atlanta-based Emory Healthcare, said in remarks accompanying the announcement.
"Stratus Healthcare is one of the largest and most successful collaborative healthcare partnerships in the United States. We look forward to strengthening this well-established network with access to Emory's highly specialized tertiary and quaternary services in order to benefit an even greater number of Georgians with complex healthcare needs," Lewin said.
Under the affiliation, which is being finalized, Emory will tailor service agreements with Stratus facilities, focusing on telemedicine, clinical research participation, knowledge transfer and education, workforce planning, and enhanced clinical service offerings in ways that match each Stratus member's specific needs.
The affiliation will initially focus on four key areas:
Coordination of Clinically Integrated Network activities
Collaboration on development of integrated care systems and information technology infrastructure.
Provider relationships
Streamlined access to Emory's quaternary and specialized tertiary services.
Outpatient scheduling
Expedited access to Emory Clinic's single and multi-specialty clinics.
Electronic Medical Record Coordination
Emory and Stratus physicians will establish medical record connectivity to ensure coordination of care.
In addition, the partners said they will provide clinical consultation and treatment services through telemedicine and continuing medical education programming.
Stratus Healthcare is a non-profit limited liability corporation and non-equity partnership based in Tifton, GA that was formed in 2013 and includes 21 hospitals and approximately 1,500 physicians.
"With Emory Healthcare's extensive specialized medical services and educational strengths, this enhanced collaborative will assist hospitals, health systems and physicians across the region in working together for the development of consistent best medical practices," said Dean Burke, MD, chairman of Stratus Healthcare and CMO for Memorial Hospital and Manor in Bainbridge, GA.
"Shared services will be designed to lower costs while improving value for patients, physicians, providers and payers."
Nonprofit Emory Healthcare, an academic healthcare system, includes six hospitals and more than 2,000 faculty members and a network of physicians in 70 specialties at multiple offices and clinics across Georgia.
Reducing overuse of 28 low-value services such as spinal injections and imaging for non-specific head and lower-back pain could lower overall healthcare spending and improve quality, a RAND study suggests.
A research letter out this week in JAMA Internal Medicine suggests that considerable savings could be generated by reducing the use of a wide array of low-value health services among adults with commercial health insurance.
The study by researchers from the RAND Corp. and the University of Southern California examined insurance claims from more than 1.46 million adults from across the nation and found that spending on 28 low-value medical services totaled $32.8 million during 2013 within the group. That accounted for 0.5% of total spending or more than $22 per person annually.
"Our findings add evidence to the notion that reducing overuse of medical procedures could improve quality while reducing spending," said Rachel Reid, MD, lead author of the study and a RAND researcher.
Researchers examined medical services that experts have agreed provide little value to patients given the cost and available alternatives. The greatest proportion of spending for low-value services was for spinal injection for lower-back pain at $12.1 million, imaging for uncomplicated headache at $3.6 million and imaging for nonspecific low-back pain at $3.1 million.
By some estimates about $200 billion in healthcare spending nationally is for overtreatment. To reduce that amount, the American Board of Internal Medicine Foundation and consumer groups launched the Choosing Wisely campaign in 2012 to encourage physicians and patients to talk about evidence-based medicine.
"The services in this study reflect many clinical areas and types of care, but still are a small portion of all the low-value care patients receive," Reid said. "The potential savings from reducing these low-value services and others are substantial."
'Disparities in healthcare Cut Two Ways'
The analysis of 28 low-value procedures found that 7.8% of the patients studied received low-value services in 2013. Low-value spending was lower among patients who were older, male, black or Asian, lower-income or enrolled on consumer-directed health plans, which have high member cost-sharing.
"Disparities in healthcare cut two ways. [They] can cause poor access to high-value care among vulnerable patients and overuse of low-value care among more-advantaged groups. Both need attention," said Neeraj Sood, senior author of the study and director of research at the Leonard D. Schaeffer Center for Health Policy at USC.
Researchers say that among the issues that should be better understood before interventions are created to reduce the use of low-value are why more-advantaged groups receive more of the care and whether people in consumer-directed health plans also had lower levels of high-value healthcare.
While previous studies of low-value medical care have focused on Medicare recipients or narrower regions, the RAND/USC study evaluated the care received by a large group of nonelderly adults insured through one of the nation's largest commercial health insurance companies. Regionally, the Southern, Middle Atlantic and Mountain regions had proportionately more low-value spending.
"Areas with high Medicare spending also seem to have greater use of low-value services among those with commercial insurance," Sood said. "This confirms that there are opportunities for cost savings, and that both private insurers and Medicare can benefit from efforts to reduce use of low-value care."
DOJ says health system "willfully" delayed repaying $844,000 in Medicaid overpayments. Mt. Sinai says its "good faith" effort to identify the overpayment in 2011 was "time consuming and complicated."
Federal and state prosecutors in New York City this week announced a $2.95 million fraud settlement with Mount Sinai Health System stemming from $844,000 in Medicaid overpayments identified by a whistleblower in 2011.
The hospitals named in the settlement include:
Mount Sinai Beth Israel
Mount Sinai St. Luke's
Mount Sinai Roosevelt
Continuum Health Partners, Inc. (the hospitals' former partnership group)
The Mount Sinai Health System was formed in September 2013, when Continuum Health Partners combined the Hospitals' operations with those of Mount Sinai Medical Center.
"When Continuum learned that it had received over $800,000 in potential overpayments from Medicaid in 2011, it had an obligation under the law to return those funds within 60 days," Preet Bharara, U.S. Attorney for the Southern District of New York, said in a media statement.
"Instead, Continuum delayed repayment for more than two years and only fully repaid the Medicaid program in 2013. With this settlement, Continuum has made admissions and is paying $2.95 million for its fraud on Medicaid."
Mt. Sinai Health System denied claims that it was attempting to deceive auditors and said it was "fully committed to compliance and the maintenance of a vigorous compliance program."
"The circumstances relating to this settlement occurred before Continuum joined Mount Sinai and stem from a third party insurer's computer error," the health system said in a media release.
"When Continuum became aware of the computer glitch, it worked diligently with the insurance company to correct the error and directed its own staff to identify and refund any overpayments. The process for identifying the refunds was complicated and time consuming, but Continuum continued with the process in good faith until all the refunds were finally identified and repaid, well before it became aware of this lawsuit."
According to the New York State Comptroller's office, in February 2011, an internal investigation by Continuum identified approximately 900 claims totaling over $1 million that may have been wrongly submitted to and paid by Medicaid.
The list, created by the whistleblower who filed this qui tam lawsuit, contained all of the claims that were affected by the software glitch. Rather than using the list to repay the claims, Continuum terminated the whistleblower, failed to bring the list to the attention of the Government, and took nearly two years to complete its repayments.
Medicare patients who maintain relationships with the same physicians have better odds of staying out of emergency departments, research shows.
Traditional Medicare patients who consistently see the same outpatient physician have lower odds of visiting the emergency department, according to an Annals of Emergency Medicine study.
Researchers studied the administrative data of more than 3 million Medicare beneficiaries between 2011 and 2013 and found that the relative risk of an ED visit, observation stay, or admission through the emergency department fell by up to 20% for patients with the highest continuity of care, compared with the lowest continuity of care.
"Visits with the same physician or a small number of physicians fosters long-term relationships for Medicare patients, which is ultimately good for their health," said lead study author David Nyweide, a social science researcher at the Centers for Medicare & Medicaid Services.
"The critical factor seems to be consistent visits with one physician or few physicians, not lots of them," Nyweide said. "Seniors would be well-advised to maintain an ongoing relationship with the same physician for many reasons, including avoiding emergency department visits."
The study found, however, that when an ED visit occurred the patient was more likely to be hospitalized. Among beneficiaries with ED episodes, higher continuity was associated with a 1% lower risk of observation stay but a 3% to 4% higher risk of hospital admission relative to an ED visit with discharge home.
"One possible explanation is that when a patient with a usual care physician comes to the ER, the physician may provide clearer guidance on which situations are serious enough to warrant a hospital admission," Nyweide said.
In related news, seniors in the ED might benefit from one that's designed for them. Geriatric EDs, such as the one at Mount Sinai Hospital in New York, may have the potential to lower healthcare costs and reduce hospitalizations for the elderly. Care is specifically tailored for them and providers are able to better determine who needs hospitalization and who doesn't.
Eight CommonWell Health Alliance member organizations have committed to supporting patient access to healthcare data. Two say they will make it happen this year.
By the end of 2016, consumers will be able to self-enroll in the CommonWell network, link their healthcare records from wherever they receive care, and browse the data via a variety of online methods.
CommonWell is a not-for-profit trade association of health IT vendors representing two thirds of the acute care and one third of the ambulatory care electronic health records market, as well as other vendors from across the health IT spectrum, including post-acute care, imaging, laboratory, and population health vendors, as well as retail pharmacies.
Eight CommonWell members have announced they will support the initiative; six have not set a specific timeframe for deploying the capability:
Cerner
Athenahealth
Modernizing Medicine
Aprima Medical Software
Evident
RelayHealth, a division of McKesson
Two more member organizations, providers of patient portal and personal health record technology, said they will also support the patient access initiative. MediPortal and Integrated Data Services intend to provide patient access to CommonWell health data by the end of 2016.
The data stored by CommonWell is the core standard clinical chart data set, as typified by the CCDA standard, required for meaningful use, according to CommonWell officials.
CommonWell services are already live on more than 4,700 hospital, ambulatory, and post-acute provider sites, with an additional 3,300 sites committed to using CommonWell services.
While nearly 74% of health care consumers surveyed by patient engagement technology provider HealthMine say easy electronic access to health data would improve their knowledge of their health and improve communication with their physicians, 53% of patients surveyed said they cannot access their data online.
A nursing association takes issue with the American College of Surgeons' guidelines for clinician attire.
By Alexandra Wilson Pecci
A dress code for surgical teams intended to "support professionalism on behalf of patients," has been met with questions from a nursing group, which says the code lacks rigor.
The guidelines on operating room attire issued by the American College of Surgeons this month notes the symbolism of the skullcap to the surgical professional, and says that the skullcap "can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered."
The iconic, wing-tipped nursing cap is a symbol of the nursing profession, but that doesn't mean it has any place in the operating room, says Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, Director of Evidence-Based Perioperative Practice for the Association of periOperative Registered Nurses (AORN).
"It's all about patient safety," she says. "It's not about our symbolism. It's not about how we look."
Basing guidelines on symbolism and hard-to-define notions such as modesty is problematic, AORN says.
"How does one enforce something like that? What is a modest sideburn?" Spruce asks. "It's very open to interpretation, and we need to be very clear."
That's why AORN last week issued a detailed response to the ACS's statement on attire, and the skullcap is only one of the elements that it takes issue with.
"Of particular concern to AORN and its membership of 40,000 perioperative registered nurses, is the introductory statement: 'The ACS guidelines for appropriate attire are based on professionalism, common sense, decorum, and the available evidence,'" AORN's response states.
It continues, "Regulatory agencies, accrediting bodies, and patients expect health care organizations to follow guidelines that are evidence-based rather than recommendations based on professionalism, common sense, or decorum."
Spruce notes that when it comes to patient safety regarding attire, regulatory agencies such as The Joint Commission and the Centers for Medicare & Medicaid Services don't cite decorum as an influencing factor.
"What they expect, she says, is that people are going to follow… evidence-based guidelines."
Although ACS says that "Soiled scrubs and/or hats should be changed as soon as feasible and certainly prior to speaking with family members after a surgical procedure," AORN notes that OSHA already requires that "attire that has been penetrated by blood, body fluids, or other infectious materials be removed immediately or as soon as possible and be replaced with clean attire."
"We need to follow the law, which is OSHA," Spruce says.
Another Set of Guidelines
The AORN response goes point-by-point through the ACS's guidelines, noting which are evidence-supported (the guidelines against dangling masks); which are not (changing scrubs and hats between cases); and those on which AORN has no opinion (wearing "clean appropriate professional attire [not scrubs] to be worn during all patient encounters outside of the OR.").
AORN notes that it already has its own guidelines for surgical attire that Spruce says should apply to all members of the surgical team. In addition, the "AORN guideline development process meets the rigorous requirements of, and [is]accepted by, the AHRQ National Guidelines Clearinghouse," the AORN response says.
This raises the question about whether the same type of development process was followed for the new ACS guidelines.
"It doesn't appear that they did a systematic review of the evidence because there wasn't any evidence cited," Spruce says that she was not aware of a public comment period before the ACS guideline was approved. "We didn't have any idea that it was coming out."
"We have to be a team, and everybody has to be practicing the same way," she says.
A 7.2 percent closure rate was observed by researchers; critical access hospitals are more likely to close their OB units than other rural hospitals.
Rural hospitals that shut down obstetrics (OB) services between 2010 and 2014 were smaller and more likely to be privately owned and located in low-income communities, according to a new study.
A telephone survey of 263 rural hospitals in nine states found that 19, or 7.2 % had closed OB units. The study was conducted between September 2013 and March 2014 in Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin.
Hospitals cited staffing, low volume, and low reimbursement rates as the top three factors in the decision to close, according to findings published in the journal Health Service Research.
The University of Minnesota researchers found that critical access hospitals were more likely to close OB units than other rural hospitals. Fifteen of the 19 hospitals that closed unit reported that the most common reason for closing was difficulty finding staff including "retention, recruitment, and liability issues surrounding obstetricians."
Two of the closed hospitals reported women in their communities were left with no local access to prenatal care. Instead they would need to travel 25.4 miles and 40.8 miles to the nearest hospitals where OB services are available.
The hospitals reporting that prenatal service were available locally noted that patients need to travel an average of 29 miles for obstetric care.
The researchers note that public hospitals may be less likely than private hospitals to close units because of the "focus on community needs."
They also suggest that a range of additional factors may play into a decision to close a unit, including "leadership, political environments, the dynamics of the OB practice model, and patient-provider relationships."
Among the hospitals that closed their obstetric units, the chief reasons for closure were:
Difficulty in staffing the unit, including retention, recruitment, and liability issues surrounding obstetricians
Low birth volume
Low reimbursement
Other financial issues, such as surgical and anesthesia coverage and the cost of operating the units, and budget cuts
The researchers note that the fact that most women continued to have access to prenatal is "encouraging," but suggest the need for better communication between local providers and distant hospitals.
"Ongoing efforts should focus on encouraging linkages between maternity care providers and hospitals in perinatal systems of care, including using telemedicine and health information technology to help ensure continuity of maternity care," they conclude.
Study estimates that in states where Medicaid has been expanded, hospitals' uncompensated care costs have decreased from 4.1 percentage points to 3.1 percentage points of operating costs.
In states that have expanded Medicaid to cover more low-income adults, the healthcare reform initiative is achieving a primary goal: cutting uncompensated-care costs at hospitals, research shows.
The research, published this week in the journal Health Affairs, was conducted by three professors at Northwestern University's Kellogg School of Management. The study examines uncompensated-care costs at 1,249 U.S. hospitals between 2011 and 2014.
"The Affordable Care Act represents the largest expansion in health insurance coverage in the United States since the creation of Medicare and Medicaid in the 1960s," the study says. "We provide the first broad-based national estimates of the decline in uncompensated care resulting from the enactment of the ACA."
Medicaid expansion has reduced uncompensated care in states that have taken advantage of the program and represents a missed opportunity for the 19 states that have shunned Medicaid expansion, the study suggests.
It estimates that in states where Medicaid has been expanded, uncompensated care costs have decreased from 4.1 percentage points to 3.1 percentage points of operating costs.
"The reductions in Medicaid expansion states were larger at hospitals that had higher pre-ACA uncompensated care burdens and in markets where we predicted larger gains in coverage through expanded eligibility for Medicaid. Our estimates suggest that uncompensated care costs would have decreased from 5.7 percentage points to 4.0 percentage points of operating costs in nonexpansion states if they had expanded Medicaid."
The study's authors defined uncompensated care costs "as the sum of losses on charity care and bad debt." They based their findings on data collected from Medicare Hospital Cost Reports, which must be filed annually by all hospitals that receive payments from Medicare.
For 2014, Medicaid expansion had more of an impact on uncompensated care reductions than any other healthcare reform initiative on a national scale, the study says.
"Using the experience of expansion states as a guide, we predict that had nonexpansion states expanded Medicaid, uncompensated care costs in those states would be nearly 30 percent lower than they are today."
The study notes the Marketplaces, publicly administered health insurance exchanges that were also launched in 2014, could help reduce uncompensated care eventually. "Over time, enrollment in the ACA's health insurance Marketplaces, compliance with the individual mandate, and state Medicaid expansion decisions are all likely to lead to further changes in uncompensated care."
Furthermore, Medicaid expansion was found to have reduced uncompensated care variability between hospitals in states that have adopted the program.
"The reductions in uncompensated care costs in Medicaid expansion states in 2014 were driven by hospitals that had the highest levels of uncompensated care in 2013. … Because hospitals with the largest uncompensated care burdens saw the largest reductions after the Medicaid expansions, the variation in uncompensated care costs across hospitals in expansion states decreased."
Medicaid expansion appears, however, to have exacerbated uncompensated care variability on a state-by-state basis.
"The variation in uncompensated care among hospitals declined within expansion states, even as it increased across the states. From 2011 to 2013, hospitals located in nonexpansion states provided more uncompensated care costs than hospitals in expansion states, and the implementation of the ACA only served to increase this divide."