One in seven Americans under age 65 went without prescribed medicines in 2007 as drug costs spiraled upward in the United States, according to the nonprofit research group Center for Studying Health System Change. That figure is up substantially since 2003, when one in 10 people under 65 went without a prescription drug because they couldn't afford it, according to the Center. "Our findings are particularly troublesome given the increased reliance on prescription drugs to treat chronic conditions," said Laurie E. Felland, the study's lead author. "People who go without their prescriptions experience worsening health and complications."
Nurses want to, and should be, included in the discussion when physicians talk to patients about serious medical mistakes that were made, a new study shows. The study said nurses play a critical role with the patient and leaving them out of such discussions weakens the disclosure experience for the patient or their family. The authors call for a team disclosure process that follows established policies allowing nurses and other caregivers into the mix. They also suggest training be provided about how to talk to patients and families about errors.
The increasing financial pressure on the healthcare market is leading to consolidation of a growing number of healthcare organizations, including physician practices.
Although there are many benefits to merged entities, as with any venture, there are a number of drawbacks that must also be considered. These can include, but are not limited to, the following.
Merger costs. Merging practices is not cheap, and participants often underestimate the expenses associated with such a venture. Two distinct types of costs will be incurred in a merger process. First there are formation costs, which typically include legal and consulting costs to form the merged entity on paper. Generally, consultants are used to facilitate the decision-making process and then attorneys are used to draft the actual legal agreements for the merged entity and perform any necessary legal due diligence. To get the new practice operational, participants will also incur several operational expenses, such as the cost to purchase equipment, add employees, procure new facilities, and so on.
Both types of costs can vary widely with each merger. For example, some physicians who already employ qualified administrators to help facilitate the formation process may not need to hire consultants. The operational costs can also vary substantially based on the infrastructure of the practices that are coming together. For example, if they are all using different IT systems, the merged group will incur costs to develop one unified system. Additionally, if there is insufficient space within one of the practice’s facilities to set up a billing/management office, the entity will need to invest in a new facility.
In every merger instance, it is important to perform the necessary due diligence to understand the costs involved and develop a plan to cover them, either by taking on debt or by having each physician contribute capital.
Loss of autonomy. One of the biggest deterrents for physicians in developing a merged entity is an understanding that there will be some loss of autonomy. The sacrifice is necessary for a merged group to succeed. In a large group, it is impossible for all physicians to continue to dictate the majority of their practice operations as they were able to do in their smaller practices. Otherwise, little cost savings would be recognized and an environment that is chaotic and difficult to manage would result. Accordingly, physicians must be willing to give up some of their autonomy to realize the full potential of a merged practice.
Practices that have been in existence for a long time generally have a particular manner in which they go about practicing medicine. Accordingly, comingling operations with practices that may operate differently can be tough, not only for the physicians involved, but also for their support staff. Many times, a strong administrative leader can consider how things were done in the past at each individual practice and choose the best alternative for the new practice. It is then necessary for all members of the practice—physicians and the support staff—to buy in to the decision and go along with it.
Although not necessarily drawbacks, other potential problems could lead to the failure of the merged entity. Issues to avoid include the following:
Clinical and relational differences among physicians/practices
Poor planning, a hastily constructed business plan
Failure to identify a single macro message for the merged entity
Political difficulties among practices/physicians
Lack of transition management
Defensive motivation (e.g., participating in the merger only to maintain current market position)
It is important that all of these issues are indentified early in the merger process to ensure that they can ultimately be overcome.
It has already passed in the House, and the legislation to expand the State Children's Health Insurance Program will likely make its way through the Senate with little resistance. After all, who would want to deny emergency health coverage to children who need it, particularly in a time like this?
Therein lies the brilliance of opponents of physician-owned hospitals, who have buried in the SCHIP bill a provision aimed at curtailing the growth and development of these facilities. The restrictions aren't currently in the Senate version of the bill, and it's unclear if they will make it into the final legislation. If they do, existing physician-owned hospitals would be barred from expanding, investment in such hospitals would be restricted, and no new Medicare reimbursement approvals would be issued.
It's an old trick in Washington—you hide potentially controversial measures in a must-pass bill to limit debate and tie opponents' hands—and it is a familiar tactic in this old fight.
In 2008, similar language was slipped into several bills, including legislation related to funding the war in Iraq and a completely unrelated farm bill, but the ban never passed. As I wrote last spring, this is a very divisive battle involving both physician and hospital heavyweights.
Physician owners contend that their specialty hospitals offer patients greater choice and better care, while hospitals warn that physician ownership can lead to self-referrals and doctors cherry-picking patients.
Both sides make a valid point or two, and it is a debate worth having—just not like this.
Although it may not fit the technical definition, the provision in SCHIP is essentially an earmark. A number of hospitals have lost market share to physician-owned competitors, and the ban could have a substantial financial impact on their bottom lines.
Are there legitimate concerns about self-referral? Sure. But CMS already has an elaborate process for dealing with that issue. Why not debate the constraints to put on physician hospital ownership through the usual channels?
I suspect it is because hospital associations are afraid they would lose. There are already 199 physician-owned hospitals nationwide, and another 85 currently under development, according to Physician Hospitals of America. That represents "$2.4 billion in total payroll, $509 million in federal taxes, $1.9 billion in trade payables, and 55,000 full- and part-time employees."
Physician-owned hospitals have already proven their utility. CMS has investigated the claims and given them the green light. An open debate would likely focus on how to regulate these entities, rather than whether or not they have a right to exist.
"The real issue at the heart of this is competition and control," says Molly Sandvig, executive director of Physician Hospitals of America. Opponents of physician-owned hospitals don't want regulated competitors. They'd prefer to not have the competition at all, which is why they keep trying to sneak a ban by Congress.
To borrow a phrase from the new President's inauguration speech this week, the time has come to set aside childish things. Physician-owned hospitals have the right to exist, but can be improved by greater transparency and accountability. That goes for this debate, too.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.
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The proportion of children and working-age Americans who went without a prescription drug because of cost concerns jumped to one in seven in 2007, up from one in 10 in 2003, according to a study released by the Center for Studying Health System Change and funded by the Robert Wood Johnson Foundation. Rising prescription drug costs and less generous drug coverage likely contributed to the growth in nonelderly Americans who went without a prescribed medication because of cost concerns—from 10.3% in 2003 to 13.9% in 2007, according to the findings. The most vulnerable people—those with low incomes, chronic conditions and the uninsured—continue to face the greatest unmet prescription drug needs, the study found.
This article published in The New England Journal of Medicine examines the current trend that has many health systems and providers strengthening policies and oversight with regard to conflicts of interest and requiring that all industry relationships be submitted for approval. "Concerns about privacy notwithstanding, accurate, interpretable, and timely online disclosures can provide immediate access to potentially relevant information and demonstrate that relationships are not being hidden," writes the author.
The top Republican on the House Veterans Affairs Committee has demanded that the VA explain how it allowed software glitches to put the medical care of patients at its health centers nationwide at risk. Patients at VA health centers were given incorrect doses of drugs, had needed treatments delayed, and may have been exposed to other medical errors due to the glitches that showed faulty displays of their electronic health records.
On my desk sits a checklist of things I need to do this week (writing this column among them). It's nothing fancy—just a handwritten outline that I tweak as the days progress. Some items are more urgent than others; while I try to get to everything, at least a couple of tasks inevitably get bumped to the following week.
The thing is, if I'm too busy to complete every project or I just plain forget something, the consequences usually aren't terribly dire—I just work a little harder the next day or the next week. At least some of the time, I'm lucky enough to have that option in my profession. But what if a surgical team skips an item on its checklist before, during, or after an operation? Sometimes, the patient never knows the difference. Other times, the patient definitely knows the difference. And still other times, the patient dies.
A study published last week in The New England Journal of Medicine found that implementing a 19-item surgical safety checklist based on World Health Organization guidelines lowered deaths rates by nearly half and reduced inpatient complications from 11% to 7%. "Applied on a global basis, this checklist program has the potential to prevent large numbers of deaths and disabling complications," the authors wrote in the study, which involved more than 7,600 patients in eight hospitals in eight different countries over the course of one year.
I really don't need a study to tell me that a surgical checklist can help keep patients safer. I suspect most of you don't, either. Oh sure, I suppose it's nice to have concrete data to support certain suppositions, and I appreciate the efforts of the researchers. But come on. The checklist includes everything from confirming patient identity and allergies to introducing team members during timeout to postoperative instrument and sponge counts. Uh, yes—surgical teams should do those things.
What I would like a study to tell me is why such lists aren't already standard procedure everywhere. Yes, traditional surgical timeouts include many things on the WHO checklist. But addressing "most" of the list isn't good enough—all it takes is one missed item to endanger a patient unnecessarily. And I realize that ingrained cultural or operational issues in many organizations can complicate the implementation of seemingly simple procedural changes in ways I can't fully understand unless I'm a surgical clinician, which I'm not.
But is the fact that changing processes or individual behavior can be difficult any kind of excuse? "Implementation proved neither costly nor lengthy. All sites were able to introduce the checklist over a period of one week to one month," the study's authors wrote. "Only two of the safety measures in the checklist entail the commitment of significant resources: use of pulse oximetry and use of prophylactic antibiotics. Both were available at all the sites, including the low-income sites, before the intervention, although their use was inconsistent."
There you go. It doesn't cost a lot of money, it doesn't take a lot of time. Momentum has been building to make surgical checklists a higher priority; in his address at the Institute for Healthcare Improvement's National Forum in December, President and CEO Donald Berwick, MD, said the IHI is asking each hospital in the 5 Million Lives Campaign to adopt the WHO checklist in at least one operating room. And in this case, I don't believe that many providers would dispute the potential benefits of following such a list. It's the speed of change that remains to be seen.
Jay Moore is managing editor for HealthLeaders magazine. He can be reached at jmoore@healthleadersmedia.com.
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Medicaid rolls are surging, by unprecedented rates in some states, as the recession continues and Americans lose their employer-sponsored health coverage along with their jobs. In a number of states, Medicaid populations grew by 5% to 10% in the last 12 months and, in many, the growth rate was at least double what it had been in the previous year. State Medicaid officials also say that because enrollment often lags behind job losses by several months, the growth in 2008 may represent only the leading edge of heightened demand.
A bill making its way through Congress to provide more low-income children with health-insurance coverage could spell financial trouble for scores of hospitals owned by physicians. The proposed legislation will prohibit "the unethical kickbacks that physicians receive from ownership hospitals, most of which are of questionable safety and quality," said Rep. Pete Stark, chairman of the House Ways and Means health subcommittee. A provision that Rep. Stark helped write in the child-health bill would effectively put a halt to the construction of any new doctor-owned hospitals and would seriously hamper plans of existing ones to expand.
