Doctors offering second opinion consultations online are becoming more popular with patients. Patients e-mail or fax medical records and other relevant documentation, and the online doctor gets back to them in one or two weeks with a report. Though the online second-opinion market currently comprises only a fraction of the patients seeking information about diagnoses and treatment options for various health problems, it's likely to be a growing trend, according to this Newsweek article.
American College of Physicians President Jeffrey Harris has sent a letter to HHS nominee Tom Daschle asking that the Obama administration's economic-stimulus package include a 10% pay bonus for all services provided by primary care docs under Medicare for a period of 18 months. The letter also requests that primary care practices, especially small ones, get a piece of the funding pie for health information technology that Obama has pledged to spend billions of dollars on.
Compensation is far from the only factor employees consider when deciding whether to join or stay with a practice. Consider how your staff would respond to these extras:
Pension plan. Physicians at the Aesthetic Center for Plastic Surgery (ACPS), LLP, in Houston, contribute 100% to the practice's employee pension plan. "Employees don't contribute a dime," says Karen Husmann, MBA, practice administrator at ACPS.
Savings Incentive Match Plan for Employees (SIMPLE). A SIMPLE is a tax-favored retirement account for small business owners. Most plans offer an employee salary-deferral contribution feature, along with a mandatory employer contribution. Perakis, Resis, Woods & Associates Behavioral (PRA), LLC, in Schaumburg, IL, matches employees' contribution by up to 3%. "It costs the practice $10,000-plus to match everybody," says Paula M. Comm, MA, LCPC, CADC, PRA's practice administrator.
More vacation for seniority. PRA employees receive three weeks paid vacation once they've been with the practice for five years. "We try to reward people who stay long and make this a place that they can stay," Comm says.
Schedule flexibility. In some circumstances, simply being willing to work with employees who would prefer alternative schedules can bolster morale without cost to the practice. When feasible, Husmann allows employees who request flextime to try it. Flexible scheduling is usually only precluded if the employee's duties are governed by patient flow.
Continuing education. "The doctors are always very generous with continuing education," Husmann says of ACPS physicians. The practice recently sent its five-person skin care staff to New York for a weeklong seminar on skin care, paid entirely by the practice. And if an employee demonstrates an interest in obtaining further education, such as in massage therapy, Husmann will send the employee to school and reimburse the tuition over the first six months the employee uses those skills in the practice. "It's worked beautifully for us," she says.
This article was adapted from one that originally ran in the December 2008 issue ofThe Doctor's Office, a HealthLeaders Media publication.
The December 4, 2008, edition of QualityLeaders addressed the need for a third option to ease emergency department overcrowding instead of resorting to boarding patients in EDs or placing them in inpatient hallways.
Emergency departments nationwide deserve gold stars for their creativity in mitigating the effects of overcrowding by making processes more efficient through quick registration, provider in triage, bedside registration, standing orders, and the use of fast track and sub-waiting areas, to name a few. For some, there is simply no more bandwidth to utilize, no other efficiencies to be gained outside of changes intended to reduce bottlenecking for getting admitted patients to inpatient beds quickly.
Patient satisfaction surveys have shown that patients seeking care in the emergency department primarily want two things: good medical care and reasonable wait times. Boarding of inpatients in the ED inhibits the ability of ED staff to achieve both of these goals.
While growing in popularity, retail health clinics do not appear to be part of the answer, as surveys conducted by MinuteClinic have shown the bulk of patients utilizing such centers would have otherwise sought care at a physician office or urgent care center (95%), not an emergency department (only 5% of respondents).
Many point to urgent care centers or freestanding emergency departments as a model of the future, because they are not equipped to provide inpatient care and must transfer the patients to a hospital setting and are therefore immune to the ED boarding problem. But arranging transportation for a hospital admission effectively moves the admission bottleneck right back to the hospital and likely results in the patient waiting in the hospital ED, effectively doing little to solve the boarding problem but allowing some time to identify a bed. So regardless of the proliferation of urgent care centers, hospitals will still need to address the complex "admission process."
The third option that will solve this problem is to re-engineer the traditional systems that still dominate the majority of hospitals today so that there is minimal waiting for care in the ED and transportation to a clean available bed on an inpatient unit. This is a formidable challenge, as it requires the following:
Simplify the hospital admission process. The process to admit an emergency department patient to an inpatient bed is a complex one. Once the ED physician has made a decision to admit the patient, it can often be a challenge to get some hospital services to accept a patient, let alone provide a timely consultation to evaluate the patient. This can take hours. Once this hurdle has been cleared, then there's the issue of completing the required electronic and/or paper forms, creation of an inpatient chart, and identification of an available bed. If a patient is fortunate enough to have a bed identified, the chances that it is clean, the inpatient floor nurse is available to accept the report, and transportation is available to whisk the patient to his or her inpatient bed are slim to none. Even when the hospital is not at full census, the multitude of steps and subprocesses involved requires significant coordination among the ED, inpatient floor, housekeeping, transportation, patient access, and the admitting physician. Phone calls are not promptly returned. Change of shift personnel require briefing/reporting, which adds further delays. Ultimately, coordinating all the resources involved requires a consensus among stakeholders with competing priorities—hardly a simple task.
Hospital, medical, and nursing staff leadership need to understand the bottlenecks and obstacles inherent in their system that contribute to ED patient boarding. Once identified, firm guidelines need to be put in place to minimize such delays, which will not only improve patient flow in the ED but also help to reduce overall hospital LOS, as well. Some hospitals have adopted a model that decentralizes the key services of transportation and housekeeping and places them under the auspices of a patient logistics area, which can more effectively monitor and control the resources to reduce extensive delays.
Prioritization of hospital resources for the emergency department. The Centers for Disease Control reported that ED patients comprised roughly 36% of all hospital admissions. Ten years later, in 2006, that percentage had skyrocketed to more than 50%. Some hospitals rely on the ED as a source of 75% of total hospital admissions, yet provide a fewer amount of resources and priorities to the ED, in terms of staffing, space, and equipment. A recent study from the Agency for Healthcare Research and Quality found that across 65 hospitals, the majority felt their emergency departments lacked the sufficient space to deliver quality patient care with a third saying the number of patients regularly exceeds their capacity to provide safe care. Nearly 67% reported that the level of nursing staff was insufficient to effectively care for patients, and 40% felt the same regarding physician staffing.
Working to reduce non-urgent visits to emergency departments. The Centers for Disease Control reported that in 2006, there were nearly 16 million ED patients who visits were considered to be "non-urgent." While this number did not change from 2005 to 2006, it is clear that there is not enough being done to find appropriate alternative locations for these patients, whose ED occupancy prevents patients with emergent conditions from easily getting timely care. Managed care companies' increase of patient co-pay and co-insurance responsibilities may have dissuaded patients from seeking care in the ED, but this alone is not going to fix the problem. Yet many patients arriving to the emergency department for sore throats and other minor complaints are often the first to complain about slow treatment, perhaps unaware that the physician they are waiting to see is busy resuscitating a patient in the room next door.
There is no short-term or easy fix. And times are getting tougher as the potential for national healthcare reform may lend itself to continued increases in visits to EDs nationally in addition to the growing problems of nursing shortages, lack of on-call coverage, and economic challenges limiting access to capital for hospitals.
Option No. 3 in addressed ED overcrowding is a combination of significant changes by communities, their physicians, and hospitals who must all do their part to alleviate the crisis. But try to tell that to any of the one of the 42,000 patients who are admitted to hospitals from the emergency department in this country each day—I think they would prefer to be held in the ED or on an inpatient floor. Ultimately, the option No. 3 mentioned above is really not an option at all; it is a necessity.
Eric Bachenheimer is director of client solutions for Emergency Medical Associates in Livingston, NJ. He can be reached at Bachenheimere@alpha-apr.com.
Let's conduct a quick, unscientific survey. Pick a day this week to take note of every time you come across a drug or device company's branding at your practice or hospital. On your pen, maybe? On the coffee mug you're drinking from right now? On the stationary in the briefcase carried by the pharmaceutical representative who's waiting in your lobby?
Physicians' relationships with industry, pharmaceutical companies in particular, have gotten a lot of attention and scrutiny this year. State and federal government officials, as well as industry representatives, are increasingly clamping down on improper financial exchanges.
And to be fair, both parties have made some significant strides toward improving transparency and setting up some basic ground rules.
The Pharmaceutical Research and Manufacturers Association, which represents the country's top pharmaceutical research and biotech companies, adopted a voluntary code that goes into effect next week which lays out what reps should not do—give non-educational items as gifts, take doctors out for meals, and so on. On the flip side, the AMA has ethical guidelines for physicians (also voluntary) outlining what types of gifts physicians should refuse.
On the transparency front, the Cleveland Clinic recently announced that it would begin publicly posting all of its physicians' financial relationships. And several states, including most recently Massachusetts, are either investigating or are in the process of passing laws that will require public disclosure of doctor-industry ties.
But these steps are only a start. There are relationships far more nefarious than gift exchanges that still need to be addressed, including payments for articles in medical journals that endorse a particular therapy or drug. Just last week Sen. Charles Grassley, R-IA, sent letters to pharmaceutical company Wyeth as part of an investigation into the company's involvement in medical ghost writing.
These issues are a ticking public relations time-bomb for physicians. In an era of growing transparency and consumerism, each revelation about a handful of physicians profiting from industry ties erodes the public's trust in all physicians.
There are two ways this can play out. Physician organizations can take the initiative to clean up the problem themselves—and we're already seeing some of that from Cleveland Clinic and the AMA. Or, they can ignore the festering problem until the government brings down the hammer. We'll probably see more state governments move in this direction in 2009, and Grassley and others want to address it on a federal level at some point.
I recognize that there are valid reasons for doctor-industry relationships and that not all ties are inappropriate. But the public's tolerance for the interactions that do cross the line is dropping, and we're headed toward more disclosure and regulation of these relationships one way or another.
Physicians will be better off in the long run if they take the lead in making that happen.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.Note: You can sign up to receive HealthLeaders Media PhysicianLeaders, a free weekly e-newsletter that features the top physician business headlines of the week from leading news sources.
How many processes contribute to the quality of care provided in your hospital? How many measures does your organization report to someone in a given year? How many complex requirements must your hospital decipher? Contemplating such migraine-inducing questions can make a hospital leader want to hide in a dark room and lie down for a while. The sheer volume of often conflicting demands placed upon provider organizations—coupled with a deteriorating financial climate—can make the notion of improving care quality seem like an idealistic improbability at best, an impossibility at worst. Is true quality improvement a realistic goal in healthcare's current landscape?
Although I'm sure many executives whose hospitals have been deluged with bad news for months are pretty skeptical right now, the Institute for Healthcare Improvement contends the answer is yes. At the IHI's annual National Forum on Quality Improvement in Health Care last week, President and CEO Donald Berwick, MD, outlined the IHI's "Improvement Map," the organization's latest initiative designed to help hospital leaders sift through myriad regulations, measurements, and demands to hone an essential set of processes and craft an organization-specific plan for quality improvement. "You've got to face away from the chaos and toward the purpose," Berwick told attendees during his keynote address.
An ambitious concept, to be sure. The IHI's 100,000 Lives and 5 Million Lives Campaigns focused specifically on protecting patients from incidents of medical harm; the Improvement Map concentrates on "the entire landscape of outstanding hospital care," according to the summary provided in the conference materials. Berwick said the map will address "a master, overarching agenda of processes."
Sounds good, I suppose—but what kinds of specifics lie beneath the feel-good generalities? There aren't that many to be had at this point. The map does add three new interventions to the 12 from the 100,000 Lives and 5 Million Lives Campaigns:
Adopt the World Health Organization Surgical Safety Checklist.
Link quality and financial management: strategies to engage the chief financial officer and provide value for patients.
Berwick challenged every hospital in the 5 Million Lives Campaign to adopt the WHO Surgical Safety Checklist in at least one operating room within the next 90 days. A "sprint," Berwick called it. The map will also "continue to develop as we learn the shortest routes to the best outcomes. IHI will add interventions over time, clustering them by care setting and content area, and will help hospitals identify where they should focus to maximize impact," according to the summary.
My inclination, I confess, is to be cynical about all of this. Passionate calls to action are common healthcare conference fare. The Improvement Map is still in development, so measuring its potential impact is difficult, to say the least. Yes, the 100,000 Lives and 5 Million Lives Campaigns have made meaningful strides in reducing needless deaths—but a grand objective like covering "the entire landscape of outstanding hospital care" is another matter. And asking every 5 Million Lives hospital to adopt the safety checklist within 90 days? That's more than 4,000 hospitals.
But all of that said, I'm vowing to set aside those skeptical instincts (for now, at least). Because while I'll be watching closely as the program develops, I agree with a deceptively simple premise of the Improvement Map—that you can't implement improvements in a genuinely meaningful way if the fundamental processes intended to create those improvements are flawed. In theory, this is a concept hospital leaders have understood for a long time. In practice, it's a concept that challenges organizations across the country every day. Whether the IHI's newest initiative will be the answer is highly debatable. But merely saying "That will never work" doesn't solve anything.
Jay Moore is managing editor for HealthLeaders magazine. He can be reached at jmoore@healthleadersmedia.com.
Note: You can sign up to receive HealthLeaders Media QualityLeaders, a free weekly e-newsletter that reports on the top quality issues facing healthcare leaders.
Clayton County, GA's only hospital has two weeks to find $40 million or possibly risk wiping out its small amount of cash and closing. Southern Regional Health System officials will meet with SunTrust to ask for an extension on a $40 million debt due Dec. 31. While Southern Regional has no immediate plans to close, area hospitals in Henry, Fayette, and Fulton counties are concerned they may inherit thousands of new patients, most of whom have no health insurance.
Sen. Charles Grassley is weighing proposing legislation in early 2009 that would hold nonprofit hospitals more accountable for the billions of dollars in annual tax exemptions they enjoy. The legislation would require nonprofit hospitals to spend a minimum amount on free care for the poor, and set curbs on executive compensation and conflicts of interest, according to staff members for Grassley, the ranking Republican on the Senate Finance Committee. Penalties would be imposed on nonprofit hospitals that fail to meet the new requirements.
Boston Medical Center will layoff 250 employees as $114 million in state budget cuts are expected. Patient services will be cut, too, in areas including primary care, pediatrics, and geriatrics. These cuts will likely have the biggest impact on low-income residents and others who receive free or subsidized care.
Louisiana Secretary of Health and Hospitals Alan Levine is pushing for change in the state's healthcare program for low-income residents. He, along with Gov. Bobby Jindal, believe the best way to do that will be to apply private-sector, managed-care principles. The plan goes before a House-Senate healthcare committee this week.
