John McCain's healthcare plan has been variously described as a huge tax cut, as having no net impact on tax collections, and as a tax increase. McCain's chief policy adviser, Douglas Holtz-Eakin, said that the health plan would cut taxes for most Americans and that the campaign would offset the lost revenue with unspecified reductions in Medicare and other programs. An independent analysis found that tax cuts would cost a total of $1.3 trillion over 10 years, an estimate the campaign neither confirms nor disputes.
The process of transferring the care of a hospitalized patient from one resident to another tends to cause some amount of harm to the patient, a new study suggests. The study strengthens several previous studies that found "handoffs" can contribute to preventable injuries not resulting from a patient's underlying medical condition. Worries about the potential for handoff-related problems have grown since increased restrictions on the amount of time that residents can work result in even more frequent handoffs.
The U.S. healthcare system is under tremendous pressure to bring cost increases under control. The Centers for Medicare & Medicaid Services and the Office of the Assistant Secretary for Planning and Evaluation estimated that the country will spend an astounding $2.5 trillion on healthcare in 2008.
Even with all this money moving through the healthcare system many Americans do not have healthcare coverage because their employers do not offer it, or they cannot afford to pay their portion of the premium. Forty-seven million Americans are permanently uninsured, and an additional 43 million spend much of their time without coverage. We have an uninsured crisis in our country that is creating great imbalances in the healthcare delivery system. A significant source of this imbalance is the result of the large number of uninsured patients that are turning to hospitals for medical care. Data shows that nearly two-thirds of all uncompensated care is delivered in hospitals. In 2006 alone, hospitals nationwide provided more than $31.2 billion of uncompensated care, an increase from the previous year of $28.8 billion, according to the April 2008 issue of AHA's Trendwatch.
As the number of uninsured rises, many health systems are not able to tolerate the load of uncompensated care and are starting to bleed financially. As this problem magnifies, some health systems are beginning to fear they will go out of business. Most have reflexively moved to collect more aggressively from the uninsured as a way of discouraging them from coming to the facility in the first place. Health systems also are stepping up collections efforts for those who have used the facility. However, this approach has only temporized matters somewhat. Some health systems have witnessed escalations in uncompensated admissions because patients have stopped going to the ED because of collections, but are eventually admitted because their illness has become too symptomatic and requires inpatient care.
Credit checks, scrubbing for eligibility for coverage and credit counseling are routine activities that health systems around the country engage in today for patients without insurance.
Sadly, the care that many uninsured receive from hospitals is just the wrong care. Patients with chronic diseases cannot keep their diseases in check using the emergency department. There are only so many times that symptoms can be controlled in this setting without medications or real follow-up care in the community. Eventually, patients deteriorate and need to be readmitted. Because chronic diseases need ongoing treatment—medications, primary care and diagnostics—they cannot be managed successfully with episodically administered rescue medications and other treatments in the emergency department.
For patients who are admitted, when they are finally discharged because their disease(s) is (are) better, it is only a matter of time before the cycle begins all over again if outpatient care is not available. We would have to work hard to find a more expensive way to take care for these patients.
As a physician, I know that outpatient primary care and medication compliance are the cornerstones for treating and controlling chronic diseases. There is no better way both medically and financially. As an executive, I would qualify judicious primary care with medication compliance as a "win-win" way to treat chronic diseases for both patients and the healthcare system. The problem is money. Who is going to pay for the outpatient care, the medications and the other medical treatments that these uninsured patients need to keep them healthy and out of the hospital?
As a society we need to figure out how we will provide coverage to the uninsured. In the meantime, I argue that it is in the best interest of health systems to pay for outpatient care for uninsured patients with chronic diseases that are already using the hospital for medical care on an ongoing basis.
Outpatient care and medicines are much better economic options than repeated ED visits and hospital admissions for the health systems incurring these costs. In addition, for many hospitals, uninsured occupancy impedes reimbursable care, so the financial implications are more than just the uninsured costs.
Sponsoring outpatient care and medicines for high-cost uninsured patients with chronic diseases who wind up in the hospital multiple times per year makes great economic sense for health systems. The net financial impact can be significant, and the medical and moral value is unquestionable. Granted, paying for outpatient medical care for uninsured patients is not a typical hospital mission, and it is certainly not a core business practice. However, when hospitals examine their spend on uncompensated costs they are likely to find that a relatively small number of patients drive much of the costs. These are the patients that the health system needs to consider helping.
Developing and deploying a care management program to manage the medical needs for chronically ill patients on an outpatient basis is not easy. But it is a doable task. At the highest levels, health systems will need to:
Understand their uncompensated utilization and costs for patients with chronic diseases.
Identify the specific patients to participate in the program
Engage the patients
Determine the medical needs for each patient
Find and assign medical homes to patients
Address barriers to care
Address resources to care--funding for medications, transportation, therapy, etc.
Monitor the progress of these patients
Through such care-management programs health systems will develop new competencies as care managers that can be applied to all patients in their service area, not just the uninsured. The business model for health systems stands to expand to that of managing the medical needs of patients in the community—not just when they are in the hospital. This is particularly applicable for the growing number of health systems that employ physicians. For them, physician practice revenue and care management fees represent a tangible and accessible business opportunity.
To get to this point, health systems may have to develop some new competencies—like data analytics—and fortify others i.e., case management. Some health systems may choose to partner with organizations that are experienced care managers or outsource certain functions—like analytics—to be successful.
There will be risks. These programs must target the right patients, and physicians must follow guidelines of care so that good medical care is also cost effective care. There is also the fear that health systems will become magnets for sick patients without insurance. The reality is that health systems are already magnets in most instances.
This approach is not meant to cover all the medical needs for the uninsured. Most uninsured patients will not be eligible for this kind of a program because their medical needs will not match those targeted by this type of service. Also, the care does not have to be gifted. Health systems can bill the uninsured patients for this care. Perhaps collections will be no better than they are today; but the program will deliver better quality of care, reduce utilization within the facility, and be less costly to the patients who actually pay and the health systems providing care.
Our society needs to find a real solution for the uninsured. In the meantime, a care management program may do a lot of good for some very ill, uninsured patients, and bring true financial relief for struggling health systems.
Ricardo Guggenheim, MD, is vice president of Care Management Strategy for McKesson Health Solutions.
There isn't much incentive for healthcare organizations to embrace innovation. Most hospitals are paid on a fee-for-service model, so innovation isn't exactly going to bring in a huge windfall of cash. In general, hospitals provide good quality care (barring the occasional wrong-site surgery or wrong dosage of medication, of course), so why spend money or pull staff members away from direct patient care to focus on innovation. And what do employees actually get for being an innovator? A pat on the back, financial bonus, a preferred parking spot?
During the past two weeks, I have seen articles, surveys, and webcasts that have all focused on innovation. The message: You need to be innovative if you want to be successful in the future.
But there still appears to be a huge disconnect on what constitutes a truly innovative organization in healthcare. It's easy to identify innovators outside of the industry. Boeing, Disney, Apple, and Toyota are just a few of the companies that healthcare executives are looking to for ideas on how to tackle quality and safety, consumerism, product design, and process improvement in new and innovative ways.
The healthcare industry is definitely ripe for innovation. The status quo isn't working, there are emerging technologies and clinical advances that are transforming how care is delivered, and consumer expectations are evolving. Now is the perfect time to put on your thinking cap and come up with that Wow! idea that will transform healthcare and propel your organization into an elite class of innovators. There's just one problem. To be truly innovative it takes time, money, commitment, and risk. Unfortunately, healthcare organizations just don't have a surplus of all of these characteristics.
Healthcare by nature is about routine and structure?not the easiest environment to breed innovation. And people don't like change. How many times have you heard the phrase, "This is just how we have always done it"? Some healthcare employees will fight against change for no other reason than the organization has been using that particular process or product for years.
To build an innovative culture, the best place for healthcare executives to start may be with small, simple solutions that are designed to make employee?s jobs easier or the patient?s care safer. Ask employees how you can reduce emergency department wait times, eliminate falls, or reduce the amount of time spent on paperwork. The solutions offered may not be all that innovative to start. But it will get your staff thinking about ways to deliver safe, more efficient, consumer-friendly, and cost effective care. And sometimes the simplest idea can have the biggest impact?one of the most powerful tools to prevent medical errors and improve patient safety is, after all, a simple checklist. Once the idea of innovation starts to take hold in your organization and gain momentum, then you are more likely to find that Wow! idea.
Here are some of the elements that I have heard can help build a culture of innovation:
Communicate. Employees need to know more than the mission statement. They need to understand the goals of the organization and know where it is headed. This requires senior leaders to communicate, communicate, and communicate with the entire organization.
Get buy-in. Look at your organization's existing culture and subcultures and address any distrust or concerns that the staff may have regarding the organization's new focus on innovation. You need employees to embrace the concept and view it as more than a passing fad. Talking about innovation isn't enough. You need to devote actual resources?money?to the effort.
Embrace change. Employees need to be open to change. Show them how change can benefit them as well as their patients. Recruit champions of change in the organization and share best practices from other healthcare facilities.
Look outside healthcare. Expose employees to innovative cultures outside the healthcare industry. This may help them think more broadly, which is an essential component of innovation.
Push the envelop. Organizations need to tolerate risk and be able to abandon projects. Not every idea is going to be a grand-slam.
Set aside time. Allocate time for staff members to research trends, discuss ideas, and develop new processes, products, or business partnerships.
Be active. Healthcare executives need to be actively involved in the process?allocating money, supporting staff, breaking down barriers, exchanging ideas, and communicating with employees.
Carrie Vaughan is leadership editor with HealthLeaders magazine. She can be reached at cvaughan@healthleadersmedia.com.
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Maple Grove Hospital, set to open in Minnesota in late 2009, announced its selection of Andrew S. Cochrane as its CEO. Cochrane is currently CEO of Methodist Willowbrook Hospital in Houston and will take his new post in early November. Maple Grove will open with 90 beds and is designed to expand to up to 300 beds.
St. Luke's Hospital in San Francisco, threatened with closure as a full-scale facility just a year ago, was reborn Thursday when its governing board approved a plan to rebuild the facility. The board unanimously voted to build a new hospital on the existing St. Luke's campus. The board also endorsed maintaining critical services at St. Luke's, including an emergency department, obstetrics and gynecology, an intensive care unit and urgent care, as well creating a new "center of excellence on senior health."
Specialty drugs—often sold by biotech companies, and used to treat complex conditions such as cancer—are some of the most expensive medicines on the market, and their prices are rising much faster than inflation, and even faster than the prices of other prescription drugs. Last year, the wholesale price of specialty drugs rose 8.7%, three times the rate of inflation, while non-specialty, branded drugs rose 7.4%, and the price of generic drugs fell by 9.6%.
Pauline Chen, MD, responds to a paper published suggesting physicians miss opportunities to express empathy to patients. "I would like to believe that I am a compassionate doctor. But when I must convey bad news to a patient, one of the first things I worry about is time," she writes.
Physicians from the University of Pittsburgh Cancer Institute and Cancer Centers are urging the U.S. House Subcommittee on Domestic Policy to support additional research into the potential health risks of cell phone use. While there is currently no definitive evidence that shows cell phone use is harmful, doctors say users should be cautious, especially when it comes to children. According to doctors, children may be at a greater risk of cell phone-related health problems, as they have thinner skulls.
The recently fired director of the Iowa Division of Mental Health and Disability Services is charging that he was let go following complaints he made about incompetent state workers and the unnecessary spending of taxpayer money. Allen W. Parks was suspended earlier this week and told it was the result of an investigation into a hostile work environment—upon his firing, officials said the investigation was not yet completed.
