With 40 swine flu cases in the U.S. already diagnosed, a number that promises to go much higher, an executive for one hospital system in San Diego County that treated some of the first cases has a few pointers for his peers.
"Stay informed," first and foremost, says Chris Van Gorder, CEO of Scripps Health. Keep in close contact with area public health agencies and the Centers for Disease Control and Prevention.
"We are keeping our leadership informed, especially our elected physician leaders, infectious disease experts, emergency departments, and clinics since they will see the patients first. And they are keeping us informed."
"Information, properly managed and communicated, will actually prevent rumors and panic," he says.
Patty Skoglund, Scripps' director of Disaster Preparedness, advises hospital officials to track the number of flu lab tests and not the number of patient visits, and track costs related to serologic testing of staff and inpatient costs with H1N1 diagnoses. They ultimately may be federally reimbursable, she says.
Van Gorder also advises hospitals to check supplies and order more. "Contact vendors to make sure they are prepared to increase supply delivery if necessary. Most hospitals use 'just-in-time' inventories now so they don't maintain excess stock." Having extra lab test kits and N95 masks are critical, he adds.
Think ahead with other community hospitals to maximize healthcare resources. Most of the time, county public health officials coordinate this activity, but if they can't or don't, hospitals will have to step in, he says. "Monitor patient capacity, isolation capacity, and equipment respiratory disease capacity," he says.
Also, he says, review plans for how to manage employees as well as their families. Providers may have family members who are ill at home and may have to stay at home to help them. "Pandemic plans must incorporate consideration of family members," he says.
The University of Pittsburgh Medical Center (UPMC) is among countless hospitals bracing for a local outbreak of swine flu cases. "We have spent most of our time concentrating on developing the proper communication for staff and physicians," says William Smith, senior director of emergency preparedness for UPMC. "This has been difficult as the CDC information keeps changing."
For example, initially the CDC recommended using airborne and contact precautions on swine flu patients, but on Monday the agency changed its position to droplet and contact precautions.
UPMC is also increasing laboratory capacity by adding a second shift and ensuring that testing materials and processes at all of the system’s sites are the same, which can be a difficult exercise, Smith said.
CDC acting Director Richard Besser, MD, says he recognizes "incredible work" being done by the medical provider and public health community in a difficult period of "uncertainty" and limited knowledge.
"These periods of uncertainty where we’re working with very limited knowledge and very limited information are very difficult and people are doing an outstanding job across the country trying to understand this," Besser says.
Though swine flu has been a hot topic in the news the past few days, the CDC said Monday that there has been only one hospitalization linked to swine flu out of the 40 cases in five states so far.
In the business world, we generally respect the sanctity of contracts and expect repercussions if we breach such agreements.
Well, there's a Joint Commission contract of sorts regarding fire safety that you might not be familiar with—though if there's ever an infringement of this contract, you'll quickly become aware of it in terms of potential conditional accreditation status.
This contract is known as the "plan for improvement," or PFI. The PFI falls under The Joint Commission's electronic Statement of Conditions (SOC), which hospitals must complete under the life safety standards.
If your facilities or safety managers discover a Life Safety Code® deficiency within the hospital, The Joint Commission allows three options to pursue:
Correct the problem immediately
Enter it into a facility work order system and complete the repair or correction within 45 days of discovery
Add a PFI for the deficiency
A PFI is essentially a pact with The Joint Commission indicating the hospital's intent to fix a life safety deficiency, says Brad Keyes, CHSP, a safety consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.
A PFI involves opening a line item for the deficiency within the e-SOC and indicating:
What type of corrective work is necessary
The potential cost for the project
An estimated completion date
PFIs are accepted by surveyors when they review your e-SOC during a survey. The Joint Commission requires you to finish PFI projects within six months of the completion date or to formally request an extension of that deadline. If you don't complete a previously accepted PFI within the six-month grace period and haven't requested an extension, your organization faces potential conditional accreditation status from The Joint Commission—a penalty that the commission has in fact meted out over the past few years.
PFIs also have financial implications, Keyes says. CEOs don't have the option of not funding a PFI previously approved by The Joint Commission.
Should funds get pulled for a PFI project in the pipeline, the organization could again risk conditional accreditation, he says.
An important point to keep in mind is that PFIs are only to correct Life Safety Code deficiencies. For example, although it is probably a sound idea to install a new sprinkler system in an existing hospital wing currently without sprinklers, under the Life Safety Code, such action isn't required because the code allows existing healthcare occupancies to not have sprinkler protection.
Trying to incorrectly put this work on a PFI, perhaps to leverage funding for the new sprinklers, might be taken by surveyors as mismanagement of your e-SOC, Keyes says.
Surgical oncologist Rajiv Datta, MD, medical director of the Cancer Program and chairman of the Department of Surgery at the 441-bed South Nassau Communities Hospital, has been appointed president of the Nassau Surgical Society. Datta joined South Nassau in 2001 and is recognized as one of the leading head and neck surgeons in the nation, and as an internationally known leader in surgical oncology. He was awarded the 2006 Cancer Liaison Physician Outstanding Performance Award from the American College of Surgeons Commission on Cancer.
Sanford Health has named David A. Pearce director of the Sanford Children's Health Research Center. The SCHRC's mission is to combine world-class scientific talent with state-of-the-art technology to conquer childhood diseases. A $20 million gift from South Dakota Philanthropist Denny Sanford in 2007 created the SCHRC, which includes a location at the Burnham Institute for Medical Research, located in La Jolla, CA and a site in Sioux Falls. Pearce will lead the SCHRC in Sioux Falls starting this summer.
Coral Springs (FL) Medical Center has appointed Carrie Greenspan, MD, OB/GYN, as chief of staff. Greenspan's appointment marks a milestone for North Broward Hospital District, aka Broward Health: She will be the first female physician to serve as chief of one of its four hospitals. During her two-year term, Greenspan will take on the responsibilities of chairing the medical council meetings, handling quality issues with physicians, and working with CSMC's administration to improve hospital facilities and services.
Jean Meyer has been selected as the new president of Providence Park Hospital in Novi, WI. She will be responsible for the hospital's day-to-day operations and will assume her role immediately. Meyer, a nurse, has held various leadership positions. Before serving as senior vice president and CNO for St. John Health System, COO for the Providence Region and interim Providence Park administrator, she served as senior vice president, COO, and CNO for St. Vincent Hospital in Indianapolis.
A new American Hospital Association survey released today reaffirms a lot of what we already knew: Hospitals are in rough shape.
Seven in 10 hospitals are reporting declining finances that they're blaming on low in-patient volumes and a decline in elective procedures, poor investment performance and a drop in philanthropy, and the costs of treating a rising number of uninsured patients. As a result, nearly half of the 1,078 hospitals that responded to the survey say they have cut staff.
Anticipating the results of the AHA survey, hospital executives, forecasters, and consultants I've spoken with say hospitals need to be careful about layoffs. They might provide short-term bottom-line relief, but that could create the groundwork for long-term problems.
"With labor being one of the biggest expenses it's natural for organizations to look there first," says Jill Schwieters, executive vice president at Pinstripe Inc. recruiters. "I encourage clients to look at those additional labor costs—the overtime, the bonus structure, the agencies—before you go after the core staffing."
Schwieters says many hospitals have pre-recession bonus structures that were designed for a time when it was hard to staff shifts. "Oftentimes those compensation plans become engrained in the payroll system," she says. "Look at all of those incentive tools to get people to work and ask ‘do we need them anymore today?' We are seeing part-time nurses pick up more shifts. We are seeing people willing to work more and you don't need to incentivize them with a bonus. You can get rid of those additional labor costs without impacting your people in another way."
Of course, reducing overtime can also create as many problems as it solves if the cuts are done with a machete instead of a scalpel. It's like the old carpenter's maxim: measure twice, cut once.
"We've been cautious about wholesale job cuts and reductions," says Michael Sachs, president and CEO of Sg2, the healthcare intelligence firm. "There are some situations that require the organization to do that, especially if they are in a dire cash situation. But what you don't want to do is go through massive staff reductions that alienate physicians and/or patients and drive them away in a short period of time."
For example, Sachs says hospitals looking to cut costs might reduce overtime by limiting operational hours at the post anesthesia care unit. That tactic, however, could also alienate physicians who have scheduling conflicts, disrupt a revenue stream, and drive those physicians and their patients to competitors.
Sachs recommends looking at historical data and projections for service lines before deciding what to eliminate. "What is historically your performance and how well can you take care of these patients? Secondly, given the changes in the economy, what are likely to be the volumes going forward?" he asks. "If you've lost money the first half of 2008 and in 2007 and the prospects for volume going forward are weak, that would be something you'd clearly want to seriously consider eliminating."
Chris Van Gorder, president and CEO of Scripps Health, says the San Diego-based health system has avoided layoffs because they have an in-house employee retraining program. "In some cases we allowed those employees to fill positions that they would not be normally fully qualified for but we will try to keep them fully employed. That is our obligation to them and maybe the overall economy to keep people employed," he says. "Having said that, we must continue to restructure ourselves and adjust to the market because if we don't we will cease to exist."
Schwieters says one of the few bright spots in the weak economy has been a temporary respite from the nursing shortage.
"We are seeing people be more flexible in what shifts they are going to work. We've seen people who traditionally would have held out for full-time are taking part-time jobs to get their foot in the door," Schwieters says. "We are also seeing nurses who haven't worked for years come back to the work force because their spouses may have lost their job or had their hours cut back. That is one reason why it isn't necessary to have a lot of those extra shift incentives that hospitals in many way were held hostage to to get nurses to work."
Schwieters warns against pruning low-hanging fruit such as tuition reimbursement and loan-forgiveness programs. "Despite the economy today, the numbers are still the numbers. There is a work force shortage. There will be into the next 10 to 15 years," she says. "We want to continue to provide resources to our existing employees as well as graduates who are going in to nursing, pharmacy, physical therapy, those in-demand critical roles that, by the way, help drive revenues in the organization. We want to make sure we aren't cutting off that pipeline."
It's important to remember that hospital employees know what's going on in the economy. They read the newspapers and watch TV and talk amongst themselves. They all have friends and family who've been impacted by the recession. Everyone's retirement portfolio has taken a hit. Employees are willing to make short-term concessions. If benefits, overtime, or bonus cuts are communicated by management as a way to avoid layoffs and other more drastic cuts, employees will likely understand.
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Jerry Kolins, MD, was skeptical the first time he heard about 23andMe, one of several companies that will take your saliva and analyze it for 29 DNA markers for diseases or traits, all for $399.
"I know this is controversial," and that the information might have the potential to "confuse the consumer or not be accurate," says the laboratories medical director for Palomar Pomerado Health, a 426-bed health district in southern California. And he is aware that researchers have not found many genetic variants for most diseases or traits or how lifestyle impacts the process.
But after giving 23andMe a try himself, he became convinced that for many of his hospital system’s patients, it would be well worth the effort and expense.
PPH was the first health system in the nation to partner with the gene testing company to sell test kits to patients. And while many genetics experts furrowed their brows at the idea, Kolins says offering the tests can educate the public about the coming era of personal genomics.
PPH buys the kits from 23andMe at a 10% discount and uses that $40 to pay nurse practitioners to give patients 30 minutes of counseling about the tests, which are offered over-the-counter at two retail walk-in clinics and Pomerado Hospital’s outpatient pavilion, one of PPH’s two acute care facilities.
Kolins believes that while the test kits themselves will not bring in revenue, they will mean more patients. "This partnership will link more members of the community with Palomar Pomerado Health, and in doing so will improve our ability to serve, and business will improve," Kolins says.
But two federal genomics experts say any such health system effort to offer personal DNA tests to consumers so early, with so much scientific uncertainty about what the results really mean, is ill-advised.
What these tests tell you is "woefully incomplete, potentially misleading and potentially falsely reassuring or falsely alarming," says Alan Guttmacher, MD, acting director of the National Institutes of Health’s National Human Genome Research Institute.
"I would spend my $399 getting some running shoes, or on a nutritionist, or smoking cessation kit if I were a smoker. But I certainly wouldn’t spend it on this. I wouldn’t have the test done even if it were free, at this point in time," Guttmacher says.
While there are a small number of situations where a person can benefit from knowing partial genetic makeup, he says, a "well-done family history" is more useful today.
He cautions that there are "potential psychological ramifications of finding out that you have certain variations that seem to increase your risk for this or that, when for any disease, today we only know few of the gene variants."
Muin J. Khoury, MD, director of the Center for Disease Control and Prevention’s Office of Public Health Genomics, also says it's too soon for the tests to have any value outside of formal scientific studies. He and others wrote of their concerns about the potential for "commercial exploitation" in an article 16 months ago in the New England Journal of Medicine.
Kolins and other PPH officials know they will be criticized. But Kolins says he benefits by knowing he does not have the gene for cystic fibrosis, and that his chance of getting prostate cancer is slightly worse than that for the average man.
"I discovered I have the variant for hemochromatosis," he adds, which could be important for his children. He has less than half the risk for macular degeneration than the general population, and is sensitive to the anticoagulant drug warfarin. "If I needed that drug, the dose for me would be less than for the average patient."
"The carrier state and the drug sensitivities are important and immediately useful," he says, adding "I believe there should be no barriers to knowledge."
He thinks PPH is "innovative and creative" in offering the tests. It is working with physicians so they can answer questions when patients learn their results. Many will be more likely to come in for more regular screening and blood workups, especially if they hear they may have a higher risk for a certain disease, he says. "It’s helping me learn about my health."
Rajiv Mahadevan, director of business development for 23andMe, says PPH is the first of many hospitals his company hopes to partner with to offer these test kits to patients with some degree of medical supervision.
"We are basically at the start of this revolution, to see how this information can be incorporated into the healthcare system," he says. "What we’re definitely not advocating is that you take this information and [use it] to make any decision to stop taking your drugs. You have to have a conversation with your physician."
Mahadevan also knows many scientists disagree with the concept of direct-to-consumer marketing of DNA testing. "If you're going to do something revolutionary and try to make a huge impact in healthcare and personalized medicine, you almost expect that you'll get pushback," he says.
"We know there is one camp that doesn’t agree, and thinks someone should instead spend the money on running shoes. And that’s fine for them. But for others who see this is the path toward personalized healthcare, it's the beginning," he says.
It may be that just taking the test will provoke some people to be more proactive about their health. Scripps Translational Science Institute, also in San Diego County, is offering genetic scans from another company, Navigenics, to 10,000 people in an effort to see if just taking the test provokes healthy lifestyle changes.
"Genome scans give people considerable information about their DNA and risk of disease, yet questions have been raised if these tests are ready for widespread public use," says Eric Topol, MD, STSI director and the study’s principal investigator. His study will determine whether the genetic testing will change a person’s "lifestyle, behavior, diets, and psyche," Topol says.
Once again research confirms what we have been hearing anecdotally: Consumers are not accessing care at the levels they were a few years ago. They are seeing their primary care physicians less and more are holding off on non-elective procedures, according to a recent Thomson Reuters consumer health survey.
The study of 12,000 households, conducted between February and March 2009, looks at the impact of the economic downturn on consumers' ability to pay for healthcare services and insurance. It also revealed who is postponing or cancelling care and why.
Here's what you should know:
The "why" behind being uninsured matters to your bottom line
The survey found a significant decrease in the number of households who are primarily covered by traditional employer-sponsored insurance, going from a high of 59% in 2008, to 54% by 2009. Interestingly, the uninsured ranks have remained constant. However, compared to three years ago, the reasons for lack of insurance are now concentrated more on affordability, says Gary Pickens, PhD, chief research officer for the Healthcare business of Thomson Reuters and lead author on the study.
"If we look inside the uninsured group it is becoming more a group defined by its inability to pay rather than a preference or a belief they don't need to be covered," he says.
In 2006, Pickens says 43% of households that were uninsured cited affordability as the primary reason. In March 2009, that number jumped to 48%. It's a huge spike, according to Pickens, who says those numbers usually change 1% or less year to year. If you look at the period between 2006 and the start of 2009, you see significant changes in consumer behavior. In the past, when times were tough, consumers would have manipulated the parameters of their health plan, changing deductible levels or the type of prescription drug coverage they had, says Pickens. Not so today. "They are dropping coverage period," he says.
This data point signals a significant amount of stress on consumers, says Pickens. The report also shows an uptick in Medicaid and other types of government insurance as the recession has progressed. "For those who lack insurance, cost and affordability are the issues and it also raises questions about their ability to self pay when care is needed and cannot be deferred," he says. In other words, providers are at risk for increased bad debt.
Big revenue makers being deferred
In 2006, roughly 15% of consumers responding to the survey said they were postponing or cancelling care. In March 2009, that number jumped to 20%. Again, a fairly big movement from a market research perspective, says Pickens. In 2006, the main reason for cancelling or deferring care had more to do with convenience. "Today that has flipped around," says Pickens.
Now it is all about cost. While the survey shows that most care being deferred today is for physician visits, 5% to 10% of respondents are also putting off care for non-elective procedures and for diagnostics and imaging services, important sources of revenue for hospitals and other providers. The only good news is those numbers haven't reached 50%, says Pickens. But everyone knows that 10% in potential deferrals, for say, colonoscopies, hurts.
Age matters
It used to be we could expect the young to put off certain types of services. In this recessionary period, Pickens says age doesn't factor in as much compared to just three years ago when it comes to deferring care. The survey found that the postponement of care is relatively the same across age and income level. "It isn't as if all the young are putting off doctor's visits and elderly people are putting off imaging visits, it is happening across the board," he says.
Unfortunately, the numbers point to more of the same. Some 28% of survey respondents said that over the next three months they expect to delay or cancel an elective surgical procedure. More than 20% report that they expect to have difficulty paying for healthcare services or insurance. Pickens says Thomson Reuters is starting to track consumer behavior monthly to monitor the impact of the economic downturn. Have we reached the bottom? Pickens' research suggests that kind of thinking might be overly optimistic.
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Critics say a new Massachusetts initiative that will require colleges to track students' problems with their health insurance coverage are not enough and do not address complaints about inadequate coverage. The rules, which are set to take effect May 1, mean that colleges will report how many times insurers refuse to pay for care and the amount of profit health insurance companies make on student plans. By state law, college students must have health insurance, but most of the current policies do not meet the minimum standards set for other plans as part of the state's healthcare reform program.
