Jonathan Oberlander, PhD, associate professor of health policy and politics at the University of North Carolina at Chapel Hill, discusses the healthcare reform proposals offered by Senators McCain and Obama.
As infection control professionals (ICP) work on the frontlines to prevent and control infections, leaders in the field stepped forward yesterday with a new compendium that for the first time puts practical recommendations to prevent six of the most common healthcare-associated infections (HAI) into one guidance.
A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals was produced by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) in partnership with the American Hospital Association (AHA); the Association for Professionals in Infection Control and Epidemiology (APIC); and The Joint Commission.
Healthcare leaders said the strategies go one important step further than previous guidelines by presenting practical recommendations in a concise format designed to help hospitals implement and prioritize their HAI prevention efforts. The Centers for Disease Control and Prevention estimates that one of every 10-20 patients hospitalized in the United States develops an HAI, with 90,000 deaths and up to $6.5 billion in extra costs.
The compendium includes strategies for preventing Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA)—two infections with increasing incidence and morbidity in acute care hospitals. Recommendations are also made to prevent four device- and procedure-related HAIs: central line-associated bloodstream infections, ventilator-associated pneumonia, catheter-associated urinary tract infections, and surgical site infections.
"I think it's a great idea to combine all the requirements in one place. That is long overdue," said Terry Burger, BSN, RN, CIC, CNA, BC, director of infection control and prevention at Lehigh Valley Hospital in Allentown, PA. "I have one place to direct my ICPs so everyone is singing off the same sheet of music, so to speak."
Representatives from the five organizations unveiled the recommendations at an October 8 press conference in Washington, DC. The Joint Commission expects all hospitals to review their risks and current practices to determine which recommendations from the compendium they need to implement, said Robert Wise, MD, The Joint Commission's vice president of the division of standards and survey methods. The accreditor will convene a group of key stakeholders next year to decide which of the strategies to add to accreditation standards in 2010, he said.
ICPs can find copies of the recommendations online.
Following up on test results may be a procedural headache for your practice, but it is a highly emotional experience for patients and therefore pivotally important. Patients are often unclear about whether they will be notified or have to contact the medical practice for their results. Is no news good news—or does it mean that the practice forgot to follow up? This question causes unnecessary worry and even, at times, avoidable harm.
Despite this, less than one-third of physicians have a system that ensures rapid, reliable feedback of results. Many say, "Call me in a week for your results," leaving the responsibility entirely with the patient. Others intend to call patients only with abnormal results, but when these follow-up calls result in telephone tag or fall through the cracks, the patient may wrongly conclude that their results are normal.
Patients want and deserve to be notified of a questionable result. They appreciate calls or e-mails with good news, too. Whatever your patients' results, they expect your practice to follow-up with them responsibly. The data on related causes of malpractice claims substantiate the strength of this expectation among patients.
With manual tracking systems, results management software, and voicemail test result solutions readily available, physicians concerned about the patient experience can easily solve this challenge. The automated solutions make it particularly easy and efficient. For abnormal findings for instance, these systems can:
Review all chemistry, blood, imaging, and lab results ordered by clinicians and highlight abnormal findings.
Allow clinicians to see results alongside the patient's previous results, along with a list of the patient's current medications and problems.
Allow physicians to forward the results with notes to other clinicians involved in the patient's care. Users can also set reminders for repeated testing. Many systems have a fail-safe method of notifying physicians nightly via e-mail if critical results have not been reviewed by other clinicians or the patient.
Support between visits and over time also provides continuity greatly valued by patients, and it increases patient adherence. There are many ways to offer patients support:
The checkback call: Many physicians schedule time daily to make a few follow-up calls to patients. Others delegate the task to a nurse or nurse practitioner. Whether you tell the patient to expect a follow-up call or you surprise them with one, your call makes the patient feel important to you and earns you high marks.
The feedback call: With a feedback call, the physician or designee calls the patient with a test result or other relevant information. Patients resent it when their physician says, "Call me in two weeks for your result." Patients wonder why they have to: Why can't the doctor's office call? And if the patient forgets, so might the provider, which can easily lead to negative outcomes.
E-mail follow-up: Lately, as more consumers are computer savvy, e-mail is becoming the preferred mode for patient follow-up. Physicians and their staff can send follow-up e-mails at any time of the day or night and the patient will receive those messages whenever he or she signs into his or her e-mail account. E-mail eliminates telephone tag and means much better accessibility between patient and caregiver.
When John McCain and Barack Obama talk about their respective plans for healthcare reform, they understandably focus almost exclusively on how patients will be affected. But what about physicians and other providers within the healthcare system?
Now that healthcare is becoming a more prominent issue in the presidential campaign, that's a question that needs to be answered.
The Senators' approaches are steered in part by their respective philosophies—at Tuesday night's presidential debate, Obama said healthcare "should be a right for every American," whereas McCain said it was a responsibility, but stopped short of calling it a right.
You can get into the nitty-gritty details of their proposals about issues like tort reform and EMR adoption on the Obama and McCain Web sites. But for now, let's consider how their two overarching approaches might impact how physicians practice.
Senator Obama's plan
In short, Obama wants to expand coverage through a combination of public and private options, including a new National Health Insurance Exchange that will offer insurance modeled on the Federal Employees Health Benefits Program. Although the plan is not universal, he would mandate coverage for children up to age 25.
How it might help physicians: Obama's approach could alleviate some of the burdens associated with uncompensated care by covering up to three-quarters of the current uninsured population, says Jonathan Oberlander, PhD, associate professor of health policy and politics at the University of North Carolina at Chapel Hill.
Uninsured patients who currently rely on the ED as their primary source of care would have better access to the preventive and primary care services that come with full health insurance. That could also boost practice bottom lines. Doctors who provide a lot of uncompensated care may start seeing revenue come in from patients who couldn't pay before, Oberlander says.
How it might hurt: We already have a pseudo-bellwether in Massachusetts. Although Obama's proposal doesn't mandate coverage for everyone, as the Massachusetts model does, the challenges may be similar.
The problem is a lack of resources to meet an increase in demand. Twelve of 18 specialties in Massachusetts are experiencing shortages, according to a work force study released this week by the Massachusetts Medical Society. Although there are a lot of factors involved—many of which are being seen across the country—the influx of insured patients has strained the understaffed healthcare system. Safety-net hospitals are struggling, and the average wait to see an internist is 50 days.
Obama offered "loan repayment, adequate reimbursement, grants for training curricula, and infrastructure support to improve working conditions" as strategies to boost the number of primary care physicians in a response to a questionnaire from the American Academy of Family Physicians.
The question, however, is timing. Insurance coverage can be expanded relatively quickly, but it will take years to train enough primary care doctors. Will the current work force be able to handle the higher patient demand in the meantime? Will costs continue to skyrocket? A recent analysis in Health Affairs criticizes the Obama plan for failing to address the economic incentives that drive healthcare spending.
Senator McCain's plan
The McCain plan is in many ways more unique and a bigger change than Obama's. It seeks to shift health insurance purchasing from the employer to the individual by offering individuals a $2,500 tax credit ($5,000 for families) to purchase private health insurance. It will also adjust regulations to allow people to shop for insurance across state lines.
How it might help physicians: McCain wants to "unleash the market and promote competition in the healthcare system," Oberlander says. Physician groups that have made strides toward transparency and catering to healthcare consumerism will continue to do well.
McCain's plan could also expand coverage by making private insurance more accessible, although that has been highly debated.
How it might hurt: One source of that debate was the same issue of Health Affairs that critiqued Obama's plan. McCain may offset his tax cuts by eliminating "the current tax exclusion of employer payments for health coverage," which the authors argue could push individuals away from employer-based insurance and expand, rather than decrease, the number of uninsured within five years.
The bigger question that has yet to be answered is how McCain's promise to allow insurance shopping across state lines would affect physician-payer relationships, as well as the overall system.
"Of course it's OK to go across state lines because in Arizona they may offer a better plan that suits you best than it does here in Tennessee," McCain said during Tuesday's debate.
But how will that affect the physician group in Tennessee whose patient population relies on one or more of the major payers in the state? Will physicians now have to negotiate contracts across state lines with dozens of companies all across the country? Will insurers adjust reimbursement rates to reflect variable costs in different locations? Will disputes and regulations be handled by the physician's state, the insurer's state, or the federal government?
"I would project that the number of doctors taking Tylenol would increase because the administrative headaches have to go up," says Oberlander. "There's already the madness of dealing with the insurers in your own state. Now you're going to take on other states' madness?"
The bottom line
Each of the plans raises questions, and neither completely addresses problems of coverage and costs, both of which are crucial elements to healthcare reform.
But from what I can gather, physicians tend to agree with the Senator from Illinois. A group called Doctors for Obama claims it is the largest number of physicians to ever endorse a candidate for political office, and as of this writing 7,369 doctors and medical students have signed their letter supporting Obama's plan.
But that's all the information I have—political pollsters unfortunately don't single out physicians. What do you think? Do you support one plan over the other, or do you think both are flawed? send me an email with your thoughts.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.
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Four people have been arrested and charged with embezzling money from a public hospital in the U.S. Virgin Islands in the Caribbean.
A U.S. government audit earlier this year accused three of the defendants of colluding with the board of the Schneider Regional Medical Center in St. Thomas to hide bloated compensation packages and lying to legislators about the hospital's cash flow.
The defendants are former hospital chief executives Rodney Miller and Amos Carty Jr.; former CFO Peter Najawicz and former hospital board chief June Adams.
The prospect of expanding subsidized health coverage to thousands of uninsured Pennsylvanians before the end of the year has died, as Gov. Ed Rendell and Senate Republicans failed to reach a compromise on the plan's price tag. Rendell expressed disappointment over the lack of an agreement, and called the Senate GOP's resistance to his efforts at a compromise "inexplicable."
Candidates in the most significant federal races in South Jersey say they have plans to help voters by cutting health costs. The staff for U.S. Sen. Frank Lautenberg, for example, has been working to reduce healthcare costs by focusing on disease prevention and early treatment. He also has worked to stop insurers from denying coverage because of preexisting medical conditions. To cut provider costs, he has supported electronic medical records.
Nearly one in four men ages 18 to 64 lacked health insurance in Davidson County, TN, in 2005, according to U.S. Census Bureau data. In addition, the Census data show that the number of uninsured people swelled in the Tennessee counties of Davidson, Rutherford, Sumner, Williamson, and Wilson from 2000 to 2005. Of Tennessee's 95 counties, only 23 saw uninsured rates drop during that time period.
John McCain's health plan would reduce the ranks of the uninsured by about 21.1 million people if fully put in place by 2010, while Barack Obama's would reduce the number by 26.6 million, according to an analysis by consulting firm The Lewin Group. McCain's plan was projected to cost more than $2 trillion from 2010 through 2019, while Obama's would cost $1.17 trillion, according to the analysis.
The impact of the worsening credit crisis is spreading to the Chicago-area hospital scene, as Lincoln Park Hospital is now up for sale. The decision is due partly because the difficulties of getting financing are making it difficult to run the facility, sources say. The facility serves many patients insured by the state Medicaid health insurance program for the poor, and hospitals have complained that Illinois is slow to pay such claims. Also, the hospital faced pressure to keep facilities up to date with the latest in amenities and medical technology to avoid losing patients to rivals.
