Fourteen clinics have opened at Vanderbilt University Medical Center's new multimillion dollar healthcare campus, with four others expected to come on board later this year. The new space has expanded the medical center's size by nearly 440,000 square feet and was designed to relieve congestion on the main campus, preserve space on campus for hospital and laboratory research programs, allow for outpatient clinical expansion, and take services into a community that was easily accessible.
The economic downturn will force more municipalities to make the tough political call of shedding financially draining public hospitals, possibly through a bankruptcy filing, according to healthcare restructuring expert George Pillari. Pillari, a managing director at restructuring firm Alvarez & Marsal, said publicly funded hospitals have been a key contributor to huge financial losses that cities and counties around the U.S. have been experiencing.
A leading Washington healthcare expert is questioning whether any major healthcare reform will happen this year or even if the proposed Medicare Advantage payment cuts will get through Congress.
Robert Laszewski, president of Health Policy and Strategy Associates, LLC, in Washington, DC, has been outspoken in his belief that policymakers have simply not found enough money to fund major healthcare reform. For instance, a major healthcare reform effort supported by Obama would cost $1.2 trillion over 10 years, but federal leaders have only been able to find $316 billion over 10 years through payment reforms, he says.
Because lawmakers haven't found a way to fund a major healthcare plan, Laszewski says interests groups and Washington insiders are presenting their own Plan Bs, which include minor tweaks to healthcare rather than wholesale reforms.
"There is a whole other scenario starting to brew out there, and it's not clear what it's going to look like--but it ain't major healthcare reform," he says. "How it impacts Medicare Advantage is in no way certain."
Support for major healthcare reform is getting dimmer, he says. "The rats are headed off the ship . . . Everybody is covering their own butt," he adds.
Laszewski has predicted major Medicare Advantage payment cuts over the past two years because the Democrats oppose the program, but times are changing rapidly.
Healthcare reform is "floundering" on Capitol Hill and the Congressional Budget Office keeps rejecting healthcare reform funding programs.
Plus, Laszewski says so-called Blue Dog Dems, which are about 50 House moderate and conservative deficit hawks, have agreed to give a two-year patch to Medicare physician fee reductions, including the 21% cut planned for January 1. This in effect means that Medicare payments won't be required to follow the statutory pay-go requirement, which means that Congress won't have to find the $38 billion that would have been saved through physician cuts by cutting other programs. Instead, the $38 billion winds up being tagged onto the federal deficit.
Though Obama has been vocal in his opposition of Medicare Advantage and the need to cut health insurers' payments, Laszewski is not sure whether Congress will ultimately approve those cuts.
Medicare Advantage payment cuts have always been linked to physician payment cuts. The thinking has been that the money saved by paying private insurers less would offset delaying physician payment cuts for another year. Now, with physician payment reductions not following pay-go, Laszewski suggests that Medicare Advantage supporters could push to not make Medicare Advantage payment cuts because they won't need to offset the physician payment reductions.
"What I think is interesting this week is we have always tied the Medicare Advantage money to fixing the doc problem, but now that the docs seem to have worked a side deal and healthcare reform is floundering, there is a scenario you can paint that Medicare Advantage does not get touched this year," says Laszewski.
In her first official appearance yesterday on Capitol Hill since her confirmation hearings, new Health and Human Services Secretary Kathleen Sebelius could have addressed a variety of topics in her opening remarks before the House Ways and Means Committee.
Maybe she could have talked about updates on the H1N1 flu or Medicare. But on this particular day, she chose to focus on the "numbers"—the numbers found in two new annual reports from the Agency for Healthcare Research and Quality on healthcare quality and healthcare disparities that were released that morning. What these numbers showed was that the country is not making much progress in achieving better quality healthcare.
Overall, she noted that the reports showed troubling findings about the status quo of the American healthcare system. "The quality report highlights that 40% of healthcare patients don't receive recommended care—and that's an ongoing situation," she told the congressional panel.
"The disparities report highlights that severe and pervasive disparities continue to persist in this county. Minority patients still receive disproportionately poor care compared to their Caucasian neighbor," she added.
For the past six years, the National Healthcare Quality Report, 2008, has had the difficult job of summarizing the state of healthcare quality. This year, it summed up the state of healthcare quality in the U.S. in one word: suboptimal.
The 160-page report noted, for instance, that only 40% patients with diabetes received the three annual exams that they need, or that one in seven Medicare patients incur an adverse event in a healthcare setting. "We can and should do better," the report states.
With the National Healthcare Disparities Report 2008, it showed that with reviewing categories of measures, quality of care and access to care, disparities exist for all population groups. And while many of these groups have access to primary and hospital care, may of individuals in minority groups lack insurance or face barriers getting everyday medical care.
The gauntlet is now down—and Sebelius appears to be up for a challenge. At the hearing, she talked specifically about central line-associated blood stream infections that strike hundreds of thousands of patients each year. But there is a "cure," she noted, by using a hospital checklist and protocol. "If implemented uniformly and on a daily basis, it dramatically reduces these results," she said.
Medicare has been studying how to reduce these infections in 10 states, and "we want to expand that protocol to all states. So as part of this effort to transform the underlying system, I'm issuing a challenge to hospitals across America to commit to using the patient safety checklist in all hospitals and reduce the serious blood stream infection in ICUs by 75% over the next three years," she said. "We want to include every hospital in every state."
And, more challenges can be expected in the future. Sebelius announced on May 6 that HHS plans to make $50 million in grants funded by the American Recovery Act available for states to help fight healthcare-associated infections, and to make $40 million available through competitive grants to eligible states to create or expand state-based HAI prevention and surveillance efforts.
So maybe at the same time in the next year—or two, maybe the numbers that we'll see associated with healthcare quality will finally show some hopeful news.
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In presenting his $3.4 trillion budget plan Thursday, which includes provisions that will cut the deficit in half by the end of his first term, President Barack Obama proposed cuts to Medicare Advantage payments to private insurers, expansion of health information technology, reduction of healthcare fraud, waste, and abuse, and improved healthcare quality.
Obama said the government will save $22 billion annually starting in 2012 by eliminating Medicare payments to private health insurances "as a broader effort to reduce healthcare costs." The Medicare Advantage program is slated for payment cuts of between 4% and 4.5% in 2010.
Medicare Advantage supporters are obviously not pleased with the announcement.
"If this amount of money is taken out, it will have a significant impact on benefits and premiums that 10 million seniors currently rely on," says Robert Zirkelbach, spokesman for America's Health Insurance Plans, which represents 1,300 companies.
Though AHIP applauds the president for making healthcare reform a top priority, Zirkelbach says, "We do not believe that seniors in Medicare Advantage should be asked to fund a disproportionate share of the cost to reform the healthcare system."
In announcing the plan Thursday, Obama said his proposal would reduce fraud, waste, and abuse, and dedicates funds for increasing oversight and fraud detection under the Medicare Prescription Drug Program, Medicare Advantage, and the Medicaid programs.
The budget has provisions to encourage "high quality and efficient care" and reduce "excessive Medicare payments."
In addition to the Medicare Advantage cuts, Obama said the budget would:
Double funding for cancer research.
Accelerate adoption of health information technology.
Reduce drug costs.
Improve food and medical product safety through additional funding of the Food and Drug Administration.
Support efforts to allow Americans to buy drugs from other countries and establishes a regulatory pathway to approve generic biologics.
Expand health coverage to low-income people.
Extend the children's Health Insurance Program and funds an additional $44 billion above the current $25 billion. "This funding provides access to nearly four million newly insured children by 2013," he said.
Expand research in autism spectrum disorder by $211 million.
Expand access to healthcare for American Indians and Alaska Natives.
Expand loan repayment subsidies for health professionals. "It will allow states to increase access to oral healthcare through dental workforce development grants," he said.
Enhance HIV/AIDS prevention and treatment, especially in underserved populations.
With a physician shortage looming, healthcare leaders are increasingly focusing on physician re-entry. The hope is that by helping physicians who have retired or otherwise left practice brush up on their clinical skills and re-enter the workforce, the industry might slow the bleeding.
However, few physician-reentry programs exist, and not all state medical boards agree on what is required to determine a physician's competence.
For physicians thinking of reentering the workforce, it can be a daunting decision. In a recent statement in AMA eVoice, AMA President Nancy H. Nielson puts it this way:
"Imagine taking a leave of absence from clinical practice. After several years, you decide you want to start practicing again. But before you can, you must pass a written examination of 3,000 questions—only six of which pertain to your specialty. If you don't pass the test, you won't be allowed to re-enter clinical practice, at least for the time being."
The American Academy of Pediatrics is spearheading The Physician Re-entry into the Workforce Project to create guidelines, recommendations, and strategies to help clinically inactive physicians re-enter the workforce. "This is the profession's early attempts to come up with a standardized approach to physician reentry," says Jonathan Burroughs, MD, MBA, CMSL, senior consultant with The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.
Twenty to 30 years ago, physician re-entry wasn't an issue, as most physicians were clinically active until they retired. Most physicians were men, Burroughs explains, and they were committed for life. "They weren't expected to take time off, either for personal fulfillment, professional interests, or family. That was not part of the culture in those days, so the vast majority of physicians followed a predictable pattern."
Clinical inactivity is common today, given the growing focus on work-life balance and the multitude of career opportunities available to physicians. "They are going back to graduate school to get their PhDs, going into administration, or choosing alternate careers," says Barbara Schneidman, interim CEO for the Federation of State Medical Boards (FSMB).
Providers and vendors alike are anxiously waiting for HHS to establish a clear definition of "meaningful use" as a prerequisite for eligibility to tap into the $19 billion in EHR incentives available under the American Recovery and Reinvestment Act (ARRA) of 2009.
What we know is that for hospitals, meaningful use will include the ability to exchange health information, provide decision support for physician order entry, and submit data related to clinical quality and other measures that HHS selects. For physicians, it will also include an electronic prescribing capability.
One big unknown is the specific quality measures hospitals must report to be eligible for incentives.
The FY 2010 Inpatient Prospective Payment System (IPPS) proposed rule that CMS released May 1 referenced the Health Information Technology for Economic and Clinical Health Act, but only to say that HHS will select the ARRA measures in a separate rulemaking process.
The proposed rule also reiterated the fact that ARRA requires HHS to give preference to those clinical quality measures that have been selected for the RHQDAPU program, and it highlights the overlap between the two efforts. Specifically, the rule states the following:
The RHQDAPU program and the HITECH Act have important areas of overlap and synergy with respect to the reporting of quality measures using EHRs. We believe the financial incentives under the HITECH Act for the adoption and meaningful use of certified EHR technology by hospitals will encourage the adoption and use of certified EHRs for the reporting of clinical quality measures under the RHQDAPU program. Further, these efforts to test the submission of quality data through EHRs may provide a foundation for establishing the capacity of hospitals to send, and for CMS to receive, quality measures via hospital EHRs for future RHQDAPU program measures.
Another big unknown is what the requirements for decision support will entail. There a variety of different elements that decision support could include, says Kelly McLendon, RHIA, president of Health Information Xperts, LLC, in Titusville, FL. For example, it could include dose range, error checking, allergy notification, protocols, clinical pathways, or templates. All of these functions are part of decision support, he says, and each one has its own unique implementation challenges.
Interoperability is perhaps one of the largest unknowns. Aside from the technical and logistical aspects of exchanging information, hospitals should consider the ramifications of information exchange with other entities, McLendon says. "What information do we send and when? Will the information from another hospital become part of the receiving hospital's legal health record?"
The laundry list of unknowns has left providers trying to make sense of the regulation. But the lack of information hasn't precluded several professional organizations from weighing in with their thoughts on what a definition of meaningful use should entail.
The Healthcare Information and Management Systems Society (HIMSS) published its definition of meaningful use on April 27—one day before the National Committee on Vital and Health Statistics (NCVHS) would hold a two-day hearing in Washington, DC on the topic.
The problem with most solutions to the primary care shortage, including the increased reimbursements that I wrote about last week, is that meaningful changes won't be seen for several years. Medical training is by necessity a lengthy process, and attempts to widen the pipeline of primary care doctors—by increasing medical school enrollments or raising payments—do little to address the problem in the short term.
But perhaps we're missing an obvious solution by thinking only in terms of training a fresh group of primary care physicians. What if current physicians—specialists—could be retrained to fill gaps in primary care coverage?
The turnaround would be much quicker because these physicians have already completed training and in many cases have a base education in primary care. It wouldn't be enough on its own, but combined with other efforts to combat the primary care shortage, it might produce quicker and longer-lasting results.
This solution hadn't crossed my mind until Dale Keshishian, CEO of HealthWorks Academies, an organization focused on building the health delivery workforce, pointed out the possibility to me in response to last week's column. For Keshishian, this was a potential unintended consequence of shrinking the payment gap between primary care and specialists. She was concerned that specialists might represent themselves as primary care providers, effectively cutting into primary care doctors' turf and providing inferior care coordination, if increased reimbursements made it worthwhile.
But I have since seen the option discussed in a more positive light. Joe Paduda argues that it would be far "easier, faster, and cheaper" to retrain specialists than to increase primary care training from the ground up. Specialists already have the medical background and could be easily trained to practice primary care with a specialist tilt. Cardiologists, for instance, could take a more active role in follow-up care and overall coordination before and after a patient undergoes a major heart procedure.
This model only works, however, if it is worthwhile (i.e., profitable) for specialists. "The primary care shortage is already forcing many specialists to provide preventive services. If they were paid more for office visits, and less for procedures, you just might see more proceduralists take on primary care responsibilities," writes physician-blogger Kevin Pho, MD.
That's looking a little more likely after last week's Senate Finance Committee hearing in which a proposal was submitted to increase primary care and rural physician pay by at least 5%.
Is that enough to entice specialists to pick up more primary care services? Probably not. But it's enough to start a lobbying war between physicians looking for higher reimbursements and physicians afraid of a reimbursement cut.
And that's part of the reason this solution might never work. Individually, physicians work together and focus on patients' needs, but as a whole, physicians operate in specialty cliques and often let specialty interests override what's best for the overall healthcare system.
Furthermore, the effectiveness of retraining specialists as primary care doctors is limited. Real primary care doctors specialize in managing co-morbidities, as well as the relationships between specialists, hospitals, patients, and families. Retrained specialists will probably only be able to provide a watered-down version of that.
"If specialists are incentivized to provide primary care, we may see a decline in the care we have come to expect from primary care physicians," says Keshishian. "Would you want your cardiologist to manage your arthritic hip? Perhaps your orthopedic surgeon could manage your early Alzheimer's disease? What kind of ongoing follow up do you think you would get from your general surgeon to manage your routine health concerns?"
So there are pros, and there are cons. And truth be told, I don't know if this is a solution worth pursuing. But given the projected severity of the primary care shortage and the unique opportunity for healthcare reform, every solution is worth at least considering.
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Medical decisions these days are increasingly recognized as being more than simply medical, with the right choice depending in part on the patient's preferences, says Peter A. Ubel, MD, in this article in the New York Times.
The Justice Department recently declassified four memos regarding the interrogation techniques approved by the Bush Administration and used by the CIA with senior level Al Qaeda members. The details of the memos made New York Times columnist Pauline M. Chen, MD's skin crawl, she says. She adds that her mind kept wandering back to one thing: the seemingly ordinary professionals who were responsible.
