State and national health experts are baffled as to how a rare and deadly strain of meningitis killed four people and infected eight others in South Florida since December, an unprecedented outbreak in the United States. The cases of the W135 strain of meningitis were disclosed by Miami-Dade health officials. They were recommending vaccinations for those in high-risk groups, mainly those living in close and crowded situations such as college dorms or military barracks.
The top doctor at Edward Hospital & Health Services has taken a similar job at the largest community hospital system in Iowa, the Naperville, IL, hospital confirmed. Alan Kaplan, MD, vice president and chief medical officer at Edward will be Iowa Health System's new vice president and chief medical officer beginning June 1, 2009, the Des Moines-based medical care provider said in a statement. In the Iowa Health System, Kaplan moves to a hospital operator with a network of facilities statewide and about $2 billion in annual revenues.
Gaps in medical knowledge are getting new attention as the federal government prepares to invest $1.1 billion in "comparative effectiveness" research and evaluate potential therapies head-to-head.
The Institute of Medicine is reviewing priorities for this type of research and preparing to issue recommendations this summer. A new 15-member panel overseeing the government's initiative has been asking for public input. The hope is that by identifying which treatments are most effective, doctors and patients will make better-informed decisions and avoid therapies that don't measure up.
More people are seeking care in Massachusetts hospital emergency rooms, and the cost of caring for ER patients has soared 17% over two years. This is despite efforts to direct patients with nonurgent problems to primary care doctors instead, according to new state data.
Visits to Massachusetts emergency rooms grew 7% between 2005 and 2007, to 2,469,295 visits. The estimated cost of treating those patients jumped from $826 million to $973 million.
The deep recession that is threatening a financial disaster for many of the nation's hospitals also may be distracting them from preparing for a mass-casualty event like a terrorist attack, an earthquake, or a hurricane.
"It would be fair to say there has been some attention diverted from this," says Rosylne Schulman, senior associate director of policy development at the American Hospital Association.
"Part of a hospital's mission is to be prepared for emergencies and disasters and to take care of their communities. However, this recent downturn has drawn some of that attention away to pure survival," Schulman says. "Hospitals are looking at the reality of their financial situation and comparing that to the relative unlikeliness of a catastrophic disaster. Their primary focus is on continuing to serve their communities as a financially viable institution."
Nearly eight years after 9/11, the nation's hospitals are still in danger of being overwhelmed by mass-casualty disasters and public health emergencies, a new HHS-sponsored study released this week shows.
However, the University of Pittsburgh Medical Center – Center for Biosecurity independent evaluation of the HHS Hospital Preparedness Program also found that hospitals have made significant strides to improve preparedness in the immediate five years after the terrorist attacks.
The Biosecurity Center was charged with conducting an independent evaluation of HHS' Hospital Preparedness Program and its impact on healthcare preparedness for mass casualty disasters. The program was established after 9/11 to improve hospitals' preparedness for all types of disasters.
The study, which evaluated HPP from 2002 to 2007, found that healthcare planning for catastrophic emergencies at individual hospitals is still rudimentary and that a large-scale emergency could "overwhelm the medical capabilities of communities, regions or the entire country and require drastic departures from customary healthcare practices."
While acknowledging that more needs to be done, Schulman says the approximately $3.4 billion in federal funding since HPP's inception has been critical to improvements in disaster preparedness. "It sounds like a lot of money, but if you divide it up among the 5,000 or so acute-care hospitals in the country, it turns out to be very little per hospital," Schulman says. "But it draws attention to the issues in hospitals. It helps to focus their internal assessments of what they have and what they need and how far they need to go."
Schulman says AHA is lobbying Congress and the Obama administration in the hopes of getting more HPP funding, or at least avoiding cuts.
The HHS study determined that the most useful indicators for measuring disaster preparedness include a hospital’s ability to surge to accommodate additional patients during disasters, how well hospitals do in training their staff for disasters and realistic exercises, and—of course—how well hospitals perform during actual disasters.
The evaluation found that hospital leaders are more supportive of disaster preparedness, that hospital disaster preparedness plans are more comprehensive and better coordinated with local emergency management agencies, and that overall disaster training has become more rigorous. In addition, hospitals have stockpiled emergency supplies and medicines, improved communication systems, and now conduct more frequent and higher quality disaster exercises.
Schulman says the hospital sector understands the importance of disaster preparedness. "This is competing with many other very important priorities and it's a hard job deciding where we are going to spend taxpayers’ dollars," she says.
The study’s findings are based on a year of research and analysis, including interviews with 133 people involved with hospital preparedness in every state and at local levels across the country.
Comparative effectiveness research (CER) is not a new concept. However, understanding what CER is, what it does, and what it could do has seemingly taken on a life of its own in recent months.
Depending on who you talk to in Washington or even throughout the country, opinions have widely varied: some say it could be an effective way to promote quality healthcare while others say it could hinder patient choices—hurting provider and patient relationships.
To understand the source of the arguments, the starting point is found in the immense economic stimulus package approved by Congress in March. Tucked into the legislation was a CER provision calling for $1.1 billion to "conduct, support, or synthesize research that compares the clinical outcomes, effectiveness, and appropriateness" of medical drugs, procedures, treatments, and devices.
The idea has been around for a while. CER moved into the national spotlight when the Medicare Modernization Act (MMA) of 2003 authorized the Agency for Healthcare Research and Quality (AHRQ) to compare clinical effectiveness and outcomes of healthcare items and services to the initial tune of $15 million annually. (This is a drop in the bucket, though, compared to the $300 million proposed for AHRQ in the stimulus bill.)
Under the stimulus package provisions, the government established a Federal Coordinating Council to hear public comments on CER and make recommendations to AHRQ, the National Institutes of Health, and the Department of Health and Human Service (HHS). The Institute of Medicine will publish recommendations on national priorities by June 30 on national comparative effectiveness.
So far, simple: Find out which treatments and procedures really work better than others, and patients and providers will flock to them. Right? Well, not quite.
Remember, this is still the year, as the Obama administration has stated, for healthcare reform. Enter stage right are numerous Republicans on Capitol Hill who have characterized CER as a move to deny patients treatment or medications in part based on cost.
One of the more vocal critics has been Sen. Jon Kyl (R-AZ), whoraised the issue April 21 when the Senate Finance Committee voted on—and approved—the nomination of Kansas Governor Kathleen Sebelius as HHS secretary. He criticized the governor for not considering "appropriate safeguards" that would prevent denial or delay of treatments based on CER—essentially rationing care based on costs. "No Washington bureaucrat should . . . substitute the government's judgment for that of a physician," he said.
Sebelius, though, has maintained that information obtained from CER can lead to better decision-making by patients and providers.
"Comparative effectiveness research is one component of building a high-quality, value-oriented health system. It is not about government rationing," said Sebelius in response to questions about CER posed by Finance Committee members in an April 2 letter. Sebelius, who was not in attendance at the confirmation hearing, added that under the MMA of 2003, Medicare cannot make coverage decisions based on that research.
But the public perception of what CER will do remains on the wary side. Will it provide better value or restrict care? In a Kaiser Family Foundation/Harvard University/National Public Radio poll released April 22, a majority of those polled supported having an outside group make decisions about which tests and treatments should be paid for insurers—until it was realized that the panel members would be selected by the government.
When asked about having an insurer pay for a more expensive medical treatment that has not been proven to be more effective than other less expensive treatments, more than half (55%) of those polled thought the insurers should have to pay for it anyway.
Similarly, at the listening session conducted by the Federal Coordinating Council on April 14, Myrl Weinberg, president of the National Health Council, which represents the interests of individuals with chronic diseases and disabilities, noted in a nationwide telephone survey a reticence by patients in her group to support comparative research. Their greatest concern was that CER will be used "inappropriately to deny access or to funnel them into a one-size-fits-all mode of care," she said.
So what to do? At the listening session, many of those participating suggested the same thing: Make sure any reforms in healthcare are designed to keep providers—and particularly patients' own physicians--in the loop when decisions are made about treatments and procedures. CER can be an important building block in providing quality healthcare—but the users of the healthcare system need to be able to know their trust is well-placed.
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The Senate plans to vote on Kansas Governor Kathleen Sebelius' nomination as secretary of Health and Human Services on Tuesday, April 28 after Senate Minority Leader Mitch McConnell (R-KY) halted a move by Senate Majority Leader Harry Reid (D-Nev) to hold a full vote this week. McConnell called for more time so GOP members could consider her selection.
The Senate Finance Committee, following mostly along party lines on Tuesday, voted 15 8 to send Sebelius' nomination to the Senate floor. However, in recent week, some Republicans have criticized Sebelius for her failure to fully report the extent of campaign contributions she received from a physician who performs abortions. Antiabortion rights groups have also lobbied Republicans to oppose the nomination because of Sebelius' support of abortion rights.
At the Finance Committee hearing, Sen. Jon Kyl (R-AZ) was critical that she did not address "appropriate safeguards" for what he said could lead to rationed treatments and services based on the use of comparative effectiveness research.
If necessary, Reid is expected to use procedural maneuvers needed to overcome any Republican filibuster, according to his spokesman. Fifty-one votes are required for confirmation.
The HHS slot is the remaining cabinet position that remains vacant in the Obama administration.
Yesterday's internal Food and Drug Administration meeting was routine and not specifically focused on its troubled device review process as suspected, according to an agency spokesperson.
"[It] was a staff meeting within the Office of Device Evaluation (ODE) at the FDA's Center for Device and Radiological Health," said FDA spokesperson Peper Long. "The director of ODE holds these with her staff as many other staff directors in other agencies and businesses do from time to time."
Premonitions about a more focused meeting are not unfounded. In January, the U.S. Government Accountability Office recommended that the FDA take another look at the safety and effectiveness of a number of already approved class III devices. These devices ranged from pacemaker programmers to a spinal screw system. (A complete list of these devices is available on the FDA's Web site.)
The FDA divides medical devices into three categories; class III categories carry the most risk for patients.
Medical staffs are still waiting to see how the FDA's review process will evolve as a result of the GAO report. Critics say it's too soft, yet hospitals see FDA approval as a safety gold stamp when approving new technologies and granting practitioner privileges to use them.
Despite the current review, hospitals should remain confident that the devices they're using have been well-reviewed by the agency, says one trade group. "The FDA has an unparalleled record in the review of medical technology and that's why it's a model for other governments as they go about their process," said Wanda Moebius, vice president for policy and communication at AdvaMed [www.advamed.org], the trade association for advanced medical technology. "I think that if there are concerns to be addressed, they are concerns of resources and we support a well-resourced FDA."
In the meantime, hospitals and other facilities that use any of the devices under review should continue to report adverse events to the FDA, says Long.
The healthcare market is more competitive than ever, and physician practices have a growing number of strategic options—from traditional ancillary services to retail service lines—to increase revenue and remain competitive. Choosing the right service line or project can greatly enhance a practice's financial stability, but the choice isn't always easy because each option comes with direct and indirect risks and rewards.
When examining the new business venture, practices should ensure that the new service maintains high quality while remaining economically viable.
"Assess that the venture that you are considering is feasible, develop a business plan, and by all means prepare a budget that goes through the economic ramifications," says Max Reiboldt, CPA, president and CEO of The Coker Group, based in Alpharetta, GA.. "Present this to your doctors; make sure they understand that there are risks."
Questions practice managers should ask include:
Will the service add to or detract from patient comfort and security?
Will patients be compliant with the care plan?
Will the physician be able to supervise delivery of services?
Will care be of comparable quality to the traditional way the service is provided?
Will the service be reimbursed by third-party payers?
What will be the revenue possibilities?
Is there the possibility of an acceptable return on investment?
"One of the underlying themes that we've looked at as we looked at various services that we have is how effectively can they meet the marketplace," says Jack Reed, president and CEO of ProHealth Physicians, Inc., a group practice in Connecticut that recently developed an ancillary sleep program. "We needed to take the community-based practices and enable them to go out and meet the marketplace based on consumer needs."
Reed suggests outlining metrics for business development and risk tolerance when developing the program so its success can be tracked effectively. "We found, too, in our initiative that it is important to have very specific goals for the program," he says. "This is really important in how you monitor its success."
A feasibility analysis can be very helpful as well. In this analysis, consider market competition, patient demand, and provider support for the service.
"One of the most important things to start your program or expand your program is to test how complementary it is to your core business," Reed says. "You have to take this opportunity to look at how much money you are willing to put into this particular initiative, what the timeline is, how you are going to get reimbursed, and how much profit will it actually generate."
This article was adapted from one that originally appeared in the April 2009 issue ofThe Doctor's Office, a HealthLeaders Media publication.
I often hear anecdotal evidence that physician leadership can make the difference between an average and a top-performing hospital service, but it isn't often that I come across actual statistical evidence to back up that claim.
The study compared a group that had placed in the top quintile of Thomson Reuters' annual ranking of the top 100 heart hospitals, which is based on clinical outcomes, and a "control group" of hospitals that had made the list only once in the last three years—still an admirable accomplishment.
Physician leadership certainly wasn't the only difference between the two groups. The top-performing hospitals tended to spend more on their cardiovascular programs, averaging $25 million over three years, compared to $14 million for the control group.
But consider the numbers when it comes to physician leadership: Roughly one-third of the top hospitals had either physician-directed management or a dyad system—a partnership between a physician and a business administrator—compared to only 8% of the control group.
And that 8% in the control group really only reflects the dyad model, where a non-physician administrator is also involved. None of the control hospitals used a management model that placed a medical director alone at the top of the service line, but 10% of the top-performing hospitals did.
The overwhelming majority of cardiovascular programs are run by a non-clinical service line administrator. And while it makes sense to have a business-savvy manager involved in investment and budgetary decisions, without a physician involved, administrators are missing half the picture, according to Joseph Knapp, MD, who works as the physician half of a dyad model for the heart institute at St. Patrick's Hospital, a 213-bed hospital in Missoula, MT.
I spoke to Knapp for the magazine article, and he told me St. Patrick's recently switched to the dyad management structure in order to better discern both the clinical and business cases for where it makes sense to invest time and energy. "The simple fact of having bean-counter, administrative folks and the doctors sitting down and talking to each other when making decisions is the crux of what we're doing," he says.
As Knapp discussed in recent roundtable discussion about cardiovascular leadership, engaging physicians, particularly those in private practice, is another essential component, particularly when it comes to quality improvement. This is an area where the skills a physician leader brings simply aren't easily transferable to someone with a business or management background.
Although the study was limited to cardiovascular programs, I suspect we would see similar results for other service lines and departments. We might also find similar numbers—only about 30%-40% of programs with physicians at the top.
Why, if physician leadership makes such a difference, don't we see more physician-directed service lines?
Perhaps it's because there isn't exactly an overabundance of physician leaders, and physicians who are interested in those types of positions often need quite a bit of training to learn the required business skills. It takes time to transition, and many hospitals may not have a physician qualified to lead at that high level.
But those that don't should start looking for one, because it obviously makes a difference.
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