Sometimes changes to cancer screening recommendations are actually just changes to cancer screening recommendations. But judging by the backlash against new breast cancer screening guidelines released this week by the U.S. Preventive Services Task Force, sometimes they represent deeper problems and frustrations with the healthcare system.
After reviewing literature on the effectiveness of mammograms and other screening methods, the USPSTF recommended against routine mammography for women 40 to 49 years old and suggested women 50-74 get a mammogram every two years. Previous guidelines recommended annual mammograms for women over 40. The study found insufficient evidence to assess benefits for women over 75, and the task force recommended against teaching breast self-examination.
Some see this as an initial foray into the realm of comparative effectiveness research, which the Obama administration hopes will improve care and keep costs down. If that's what it is, the road ahead will be bumpy, judging by the reactions.
Both physicians and patients came out firing at new guidelines. Some patients saw it as a denial of services and worried that their cancer will go undetected. Officials with the Access to Medical Imaging Coalition and the American College of Radiology flamed these fears with borderline fear-mongering language when they warned that "countless American women may die needlessly from breast cancer each year."
Not everyone was critical, however. The National Breast Cancer Coalition applauded the decision and has for more than a decade argued that there has been too much emphasis on breast cancer screening. The USPSTF report claims that screening every other year is just as effective as screening annually, and it reduces the false positives or overdiagnosis rates, which can be as high as 10%.
I don't have the clinical expertise to evaluate the soundness of the guidelines, but I think this episode illustrates the difficulty in implementing comparative effectiveness guidelines and the real cost conundrum facing U.S. healthcare.
Consider how patients, physicians, and the government approach the problem:
Patients What they say: Cancer terrifies most people. When a physician tells a patient that a specific test or procedure isn't needed 99 times out of 100, the patient's mind is usually focused on the one time that it is necessary. That 1% may be statistically insignificant to a researcher or clinician, but to the rare patient whose cancer goes undiagnosed it represents the difference between life and death. It's hard to argue numbers when someone is facing the potential end of their entire existence. The big question going forward is whether patient demand for services will be affected at all by evidence-based guidelines.
What's left unsaid: Patients can take a chance on unnecessary screenings in part because they don't directly pay for them. Insured patients do shell out thousands of dollars in premiums every year, and many would argue that they're paying for services like mammograms with those dollars. But the disconnect between the direct cost of the test and the amount paid for insurance means patients can make decisions about receiving more tests while the direct cost is shifted elsewhere.
Physicians What they say: Physicians want better evidence about which treatments and screenings work. However, they are genuinely concerned about patient care and don't want to jeopardize patient safety, so if evidence-based guidelines aren't sound, physicians aren't going to follow them.
But there are also concerns about liability if a serious illness or injury sneaks by undiagnosed, and many physicians admit that they order imaging tests defensively. Some doctors are also worried that the toothless guidelines will someday lead to financial restrictions on the care they can provide.
What's left unsaid: Let's not pretend it's not about money, at least in part. If women in certain age groups are getting mammograms half as often, it's easy enough to do the math for how that will affect the physicians who perform a high-volume of the procedure. It's tempting to blame the fee-for-service system or criticize the evidence. But there are times when a group of physicians looks at the evidence and looks at the revenue loss, and decides against what's best for the patient.
Government What they say: Comparative effectiveness research will ideally help physicians get better value—defined by the best quality at the least cost—out of their healthcare decisions. Even without "rationing care," CER can improve healthcare by giving doctors better information when making decisions. Instead of one-sided reports from drug or device companies, they would have a broad analysis of how a treatment performs when compared to alternatives.
What's left unsaid: The task force says cost was not considered in its research, and Health and Human Services Secretary Kathleen Sebelius said the recommendation is in no way government policy. But it's difficult to believe that will always be the case. Those false positives waste money, after all.
Statistics can be manipulated, and studies can be flawed. For instance, there don't seem to be any radiologists or oncologists currently on the USPSTF. Could that have affected their interpretation of the findings? Furthermore, how will the government respond if it issues guidelines based on scientific evidence and providers don't follow them? At some point, the debate over rationing and mandating care protocols may come back up.
This is just the beginning. There are similar questions about prostate cancer screenings, colonoscopies, and other procedures. Comparative effectiveness research is a solid idea, but it is going to be tough to implement. And even if it's effective, it will only get at a fraction of the cost problem.
Expanding access? It's tough politics, but easy enough. Improving quality is a challenge but many providers are making giant strides. Controlling costs, however, will prove to be the biggest challenge in remaking healthcare, and everyone involved in the system shares a little of the blame.
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Editor's note: The following article is adapted from HealthLeaders Media's new book, Orthopedics and Spine: Strategies for Superior Service Line Performance. For more information, visitwww.hcmarketplace.com.
The number of patients needing healthcare, especially orthopedic services, is growing quickly; however, the number of orthopedic surgeons to care for them is not keeping pace. Orthopedic coverage in EDs is at risk in many hospitals. Each day, more and more hospitals are paying doctors to be on call. With margins below the 2.5% level for many hospitals, this becomes an additional burden.
Despite a wealth of uncertainty, several things are for sure. Hospitals and surgeons will be asked to do more with less. Costs must be reduced while quality improves. Transparency will become mandatory. There will be winners and losers.
Those who accept the status quo and cling to the broken system of the past will not be the winners. The community hospital and its physicians must create a product and brand equal to or better than that of its larger competitors. It won't be enough for them just to think or say they are excellent; they will be asked to demonstrate their results. All the government can do is provide us with the right incentives. It cannot transform healthcare. That can be done only by those of us in the trenches.
Outlook for surgeons
Surgeons will at least be able to count on having plenty of patients. For joint surgeons, the loss of reimbursement has been significant. In 1978, a total joint replacement reimbursement was $5,000. In 1994, it was reduced to $2,100, and by 2007 to $1,280. Whether surgeons will be fairly compensated and can increase their efficiency to handle more patients is unclear.
Given the economic pressures the country is facing, surgeon reimbursement is likely to decrease in real dollars rather than rise. Affected by this decline in reimbursement, surgeons will continue to find other avenues of income, such as surgical hospitals, ambulatory surgery centers, MRI, physical therapy, orthotics, and prosthetics. Providing these profitable services once provided by the hospital has created more stress on the hospital margins. Hospitals have asked the government to curb this activity. Just when we need closer physician-hospital relations to solve our issues, we have increased tension.
Patients will continue to expect perfection from surgery. They feel that if we could put a man on the moon, we should certainly be able to provide nearly perfect healthcare. Physicians are held to a very high standard to do just that, and if they do not, they often find themselves in court. It is also unlikely that Congress will enact any significant tort reform, meaning that very costly defensive medicine and high malpractice premiums will continue.
With all this turmoil, many excellent orthopedic surgeons and large groups are now opting to become employed by hospitals. Compensation is usually based on relative value units worked. Employed surgeons still have significant governance in day-to-day practice decisions. I have observed this working quite well in many places. Goals can be more easily aligned. The orthopedic practice that I founded in 1977 has chosen this route. With the expected shortage of surgeons and national policy changes, this may be the best option for both parties. Whether employment becomes a success story for all involved will not be known for several years.
The traditional model
One of the major flaws with traditional medicine is that we don't have a comprehensive system of coordinated patient-centric care. We have an "it depends" medicine. With specialization (a good thing) has come fragmentation. Everyone operates within silos. Primary care doctors have their systems and set of beliefs, as do surgeons, anesthesiologists, professional staff members, and so on. From their viewpoint, the care they are giving is excellent. However, this individualism, which to date is sacrosanct in healthcare, leads to multiple plans of care for the same condition.
Consider that for a procedure as straightforward as a total joint replacement, there could be as many as 10 care plans for a patient in the same hospital, depending on which professionals are involved. Having that many choices is not a good idea, even if they are evidence based. Operating within these silos can be costly and potentially harmful to the patient. It reduces efficiency for the staff while increasing the risk of error.
Tomorrow, with transparency and access to knowledge, patients, employers, payers, and physicians will be able to find out who has succeeded in making this transformation.
They will seek out those institutions and physicians that can demonstrate superior performance. Patients will drive past one hospital after another to seek care at these institutions. Physicians and nurses will seek them out as the best places to work. They will become branded as destination centers.
Surgeons are beginning to realize that their reputations are tied to the hospital/patient/family experience. Therefore, it is vital that they improve the care and experience of patients. Hospitals and surgeons must create a common vision for great patient care. One solution that has proven itself very effective is to create sophisticated service lines, which we like to call destination centers of superior performance. We take the best of traditional care and management—highly trained and qualified people—combine it with the needs of our patients—great experience and outcomes—and build it into a system of care. This is done by having the physicians and hospitals come together to create systems that are patient-centric and cost-effective.
The service line approach to orthopedic care represents a huge opportunity to resolve these challenges and more. "Service line" is a term borrowed from manufacturing industries that promote product lines. Similarly, hospital service lines seek to organize care delivery by disease processes, assemble dedicated clinicians and staff members to handle the entire care process, and coordinate with overlapping service lines.
Opportunities abound
Service line development in musculoskeletal care is the perfect place to start. Primary hip replacements are expected to increase in demand by 174% by 2030, and primary knee replacements by 673%. Hip revisions are expected to increase by 137%, and knee revisions by 600%. Nationally, back and neck pain represent the second most frequent reason patients see a doctor (the first is the common cold). More than 13 million people annually visit physician offices for back pain.
Chronic back pain accounts for 15% of all sick leaves and is the leading cause of adult disability.
New surgical technologies for the spine have enabled this market to experience over 10% growth per year during the past decade. Geriatric fractures are on the rise, and many can be prevented. Sports medicine, a term used only as a marketing tool when I started practice, is now the preferred path for young orthopedists and patients to provide and receive care. Foot/ankle and hand centers are being created as well to provide patients with more comprehensive care.
Even in today's fast-changing, increasingly technological world, the principles of leadership, excellence, management, patient-centric care, measuring results, and process improvement will endure.
This article is adapted from HealthLeaders Media's new book, Orthopedics and Spine: Strategies for Superior Service Line Performance. For more information, visitwww.hcmarketplace.com.
Because of their relatively small size and close working relationships, physician practices are less likely than larger healthcare entities, such as hospitals and nursing homes, to find themselves in an employment suit.
However, employment suits do happen, and practices should watch for the following employment mistakes to reduce their likelihood:
1. Failure to properly pay nonexempt employees for breaks, lunch, and overtime training. "This is a ripe area for litigation right now," says Cherie L. Silberman, attorney at Florida-based Constangy, Brooks & Smith, LLP (CBS).
2. Inappropriately classifying hourly employees as salaried employees to avoid overtime and other compensation. Just because you slap an "assistant to the assistant manager" title on somebody's name tag doesn't make him or her exempt from overtime and other benefits. Juries salivate over this issue. CBS attorney Michael D. Malfitano recommends that physician practices undertake annual or biannual audits to ensure that they haven't improperly classified employees as exempt.
3. Failure to implement, disseminate, and follow personnel policies. What are your harassment and discrimination policies? What are your corrective action and disciplinary policies? You might have the most progressive and comprehensive personnel policies in the business, but they're useless if you don't follow them.
4. Failure to train employees. Do your employees understand the finer points of the Americans with Disabilities Act? Do they understand that harassment is not limited to sex, but can include religion, age, race, ethnicity, disability, and marital status? This training should apply to all supervisors and managers, as well as HR.
5. Failure to document promptly and accurately. Prepare every document regarding warnings, complaints, and disciplinary action as if it is being introduced at trial and you are the jury. Be objective. Get the facts, not the conclusions. The document should include the date it was created, the name and signature of the author, the name and signatures of the witnesses (when applicable), and the stated purpose of the document.
6. Failure to appropriately evaluate employee performance. Make sure your assessment of your employees is accurate. Don't fudge over the problem areas because it's difficult to refute a former employee's complaint of being wrongfully denied a promotion after a soft-hearted supervisor gave a glowing, but undeserved, appraisal. "If they make a decision adverse to that employee later on because of poor performance but there is no documentation to support that, that could look like discrimination," Silberman says.
7. Failure to adequately discipline employees. Remember, the purpose of the discipline, beyond covering your own liabilities, is to help the employee improve. Juries really dislike it when they believe that employees are blindsided with punitive actions.
8. Failure to conduct thorough investigations into employee complaints and, if necessary, take prompt remedial action. If an employee tells you he or she is being harassed, look into it immediately. Again, this is not a difficult concept, but some employers hope to avoid confrontation at all costs, often to their own detriment. Establish ground rules for the interviews, including providing the employee with an explanation about the complaint. Don't make judgments or draw conclusions. Make sure the employee answers the questions posed; listen carefully and take notes.
9. Failure to correctly designate absences under the Families and Medical Leave Act (FMLA). Eligible employees can take up to 12 weeks off under FMLA at companies with 50 or more employees if they have been employed there for at least one year, including 1,250 hours in the previous 12 months. Eligible categories include the birth of a child, placing a child for adoption or foster care, caring for a close relative with a serious health condition, and the employee's own serious health condition. This probably won't affect many of the smaller physician practices, but it's still a good idea to be aware of the law.
10. Failure to prepare for foreseeable employee terminations. If you see an employee that might be a good candidate for termination, plan for it. Document your case for termination. Provide that employee with the necessary notices, releases, and waivers. Determine whether the employee is in a protected class and ensure that the termination is not discriminatory. Make sure the fired employee's severance and vacation pay is ready and accurately assessed at the time of termination.
This article was adapted from one that originally appeared in the November 2009 issue ofThe Doctor's Office, a HealthLeaders Media publication.
Hartford-based health insurer Aetna, which provides health benefits to more than 19 million members, has announced it is cutting 625 jobs, expects to cut a similar number of jobs at the end of the first quarter of 2010, and will consolidate field offices to reduce real estate costs.
In announcing the "targeted job eliminations," Aetna said the "action is consistent with our goal of aligning our cost structure with the company's membership outlook for 2010."
Aetna, which has 35,500 employees, said the company will provide specifics about the financial impact of the next round of job cuts when that is finalized next year.
Not surprisingly, Ronald A. Williams, chairman and CEO at Aetna, pointed to the economy and possible health reform as the reasons for cutting 1.75% of Aetna's workforce.
"The economic downturn has had a significant impact on our customers. In addition, we must prepare for the impact that healthcare reform and regulatory changes may have on our business," said Williams. "Streamlining our business now will enable us to improve our competitiveness and redirect resources to areas with a greater potential for future growth. Change is never easy but, working from a position of strength, we should be able to manage through the evolving environment."
Aetna said it is making the move to "ensure Aetna's ability to meet its service and quality commitments to customers, members, and other constituents."
The laid off employees will receive severance benefits based on length of service.
The number of babies born before 37 weeks gestation—between 34 and 36 weeks—grew 20% between 1990 and 2006, a trend that carries serious implications for public health and the nation's caregivers, according to a new federal report.
"These infants are developmentally and physiologically immature" and "are more likely than term babies to suffer complications at birth, such as respiratory distress, to require intensive and prolonged hospitalizations, to incur higher medical costs, to die within the first year of life, and to suffer brain injury that can result in long-term neurodevelopmental problems."
The agency said that while it's unclear exactly what has caused this increase, it implies that the way labor and delivery are managed may be influential. For example, it said:
Recent studies suggest that the increased use of induction of labor and cesarean delivery at 34-36 weeks have influenced the upswing in the late-preterm birth rate.
The percentage of late-preterm vaginal births for which labor was induced more than doubled between 1990 and 2006, climbing from 7.5 to 17.3%.
The percentage of late preterm births delivered by cesarean also rose substantially, by 46%.
The increase in births within 34 to 36 weeks gestation also was not offset by a decline in births delivered earlier than 34 weeks, the agency said.
To quantify the problem, the CDC said that about 50,000 more babies were born in this three-week period in 2006 than in 1990. "On average, more than 900 late-preterm babies are born every day in the United States, or a total of one-third of 1 million infants, (333,461)."
The report found that while late-preterm births increased throughout the country in this period they increased by 20% or more in more than half of all states. The District of Columbia, meanwhile, saw a 16% decrease.
West Virginia leads the increase, with 53% more late-preterm births in 2005-2006 compared with 1990-1991. West Virginia is followed by Maine, 44%; Massachusetts, 43%; Kentucky, 42%; Montana, 40%; and Kentucky, 42%.
States with the least increases include California and Connecticut, 4%; Arkansas, 9%; and New Jersey, Virginia, and North Carolina, 10%.
Some may see it as the beginning of a new debate, but on Wednesday night Senate Majority Leader Harry Reid (D-NV) likened the introduction of the long-awaited Senate healthcare reform bill as the "last leg of this journey that we've been on now for some time." The new 2,074-page bill, according to the Congressional Budget Office (CBO), has an anticipated cost of $849 billion over the next 10 years, and will provide coverage for an additional 30 million people.
Reid, who was joined by several key senators involved in the completion of the bill, cited the 750,000 Americans in the past year who filed for bankruptcy.
"Over half of those bankruptcies dealt with healthcare costs. More than half the people filed bankruptcy because of healthcare costs had insurance. So, not only do we make it more affordable for every American, but we certainly do it in a fiscally sound responsible way," he said.
However, that idea will be largely debated by Republicans when the Democrats take the bill to the floor either Friday or Saturday for a vote to begin debate. Whether the Democrats will have the needed 60 votes to stop a Republican filibuster remains to be seen. If the bill advances, amendments most likely will not be considered until Nov. 30—when the Senate returns from the Thanksgiving break.
As anticipated, the bill—called the Patient Protection and Affordable Care Act—includes a public insurance option that would permit states to opt out at their request. In its analysis, CBO estimated that one in eight individuals purchasing coverage through health exchanges in the states would select the public option—for a total of about 3 million to 4 million people.
CBO noted that a public plan paying negotiated rates would attract a "broad network of providers but would typically have premiums that were somewhat higher than the average premiums for the private plans in the exchanges." In terms of determining which states would opt out, CBO anticipated that about two-third of the population would be expected to have a public option in their states. (The House bill's public option does not use an opt-out provision.)
Like the House bill (HR 3962), policies purchased through the state exchanges—or directly from insurers—would have to meet several requirements: Insurers would have to accept all applicants, could not limit coverage for pre-existing medical conditions, and could not vary premiums to reflect differences in enrollees' health.
According to CBO, enacting the bill would create a net reduction in federal budget deficits of $130 billion over the next decade. The CBO estimate also includes a projected net cost of $599 billion over the 10-year period for the proposed expansions in insurance coverage though the exchanges, increased outlays for Medicaid and the Children's Health Insurance Program, and tax credits for small employers.
To pay for this coverage, the bill includes a variety of tax increases and new fees, including:
The Medicare payroll tax for individuals earning $200,000 annually and couples earning $250,000 annually would rise by half a percentage point—from the current 1.45% to 1.95%.
Insurers providing costlier health coverage—often referred to as "Cadillac" plans—would see a 40% tax on policies worth more than $8,500 for individuals and $23,000 for families. This had been proposed in the initial Senate Finance Committee bill.
Like the Senate Finance bill (and unlike the House bill), the new Senate bill does not mandate that all employers offer healthcare coverage. However, businesses with more than 50 employees—where at least one qualifies for government subsidies—would face a penalty of $750 for every full time worker if it declines to provide that coverage.
Starting in 2014, most nonelderly people with incomes below 133% percent of the federal poverty level (this was 150% in the House bill) would be eligible for Medicaid. The federal government would pay all of the costs of covering these newly eligible enrollees through 2016. In subsequent years, the share of federal spending would vary somewhat from year to year, according to CBO, but ultimately would average about 90%.
For altering spending with various Medicare and Medicaid programs, CBO estimated that $491 billion could be saved over the next decade by:
Enacting permanent reductions in the annual updates to Medicare payment rates for most services in the fee for service sector (other than physicians' services). This would yield savings of $192 billion over 10 years.
Setting payment rates in the Medicare Advantage program on the basis of the average of the bids submitted by Medicare Advantage plans in each market. This would provide savings of an estimated $118 billion.
Reducing Medicaid and Medicare payments to disproportionate share hospitals that serve a large number of low income patients. This would provide saving of about $22 billion from Medicaid and $21 billion from Medicare.
Senate Majority Leader Harry M. Reid presented an $848 billion healthcare overhaul package that would extend coverage to 31 million Americans and reform insurance practices while adding an array of tax increases. The Senate measure is similar in scope to legislation the House approved earlier in November. It would require most people to buy insurance, and if their employers did not offer affordable coverage, they would be able to shop for policies on new state-based "exchanges" that would function as marketplaces for individual coverage. Insurance companies would have to abide by new rules that would ban practices such as denying coverage based on preexisting conditions.
Democratic leaders in the Senate have unveiled their proposal for overhauling the healthcare system, outlining legislation that they said would cover most of the uninsured while reducing the federal budget deficit. Democrats expressed confidence that they would have the votes needed to move forward when the legislation hits its first test in the Senate. To get past that first procedural hurdle, Reid will need the votes of all 58 Democratic senators and the two independents aligned with them, the New York Times reports.
California now provides what it calls the nation's "first interactive, consumer-friendly PPO Report Card," one- to four-star rating of five of the six preferred provider organizations in the state.
Issued by California Department of Insurance Commissioner Steve Poizner, the online ranking gave the highest marks this year, only three stars—or "good"—to CIGNA, Health Net of California, and Aetna. Anthem Blue Cross and United Healthcare of California received two stars, signifying "fair."
Blue Shield of California Life & Health Insurance Co. did not report because of a technical glitch, according to an agency spokesperson.
Each of the PPO companies was ranked on delivery of care for asthma, cancer, and Chlamydia screening; diabetes, heart, and mental healthcare; testing for cause of back pain; and treating bronchitis with antibiotics. Also ranked were two categories of whether children and adults were "getting the right care."
The Web tool explains what was measured. For example, under heart care, testing cholesterol and heart attack medication were measured, and each PPO received a separate percentage score based on a comparison with national standards for quality of care.
The scoring was prepared through the selection of samples of PPO members' records to see whether they received care "that meets nationally recognized standards" based on the more than 25 Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS).
California's Department of Managed Health Care, a different state agency, already publishes a similar ranking of health maintenance organizations. Legislation took effect several years ago to require the preparation of a similar report for PPOs and it has been in the making for more than two years.
PPOs cover about 1.5 million of the state's 36 million population.
"This type of report on PPOs has never been done before," Poizner said, "but California is setting the bar higher for everyone. The value to consumers is huge, but the benefits to the entire healthcare system are even greater. We now have a baseline, and every insurer knows their performance needs to get better every year. Consumers are watching."
Association of California Life and Health Insurance Companies (ACLHIC), the trade group that represents PPOs, said in an e-mailed statement, "We are happy to participate with the Commissioner in this useful process."
"While we recognize that in many instances the ranking differences between plans represent modest percentage differences, we welcome this report as we strive for continual improvement for our members in receiving their recommended health care," said a statement issued by Anthem Blue Cross.
Health and Human Services Secretary Kathleen Sebelius said that the controversial new guidelines for breast cancer screening do not represent government policy. In a written statement, Sebelius said the new guidelines had "caused a great deal of confusion and worry among women and their families across this country," and she stressed that they were issued by "an outside independent panel of doctors and scientists who . . . do not set federal policy and . . . don't determine what services are covered by the federal government." The U.S Preventive Services Task Force had recommended that women in their 40s not undergo routine mammograms and instead individually discuss with their doctors whether to have the exams. The panel also said that women in their 50s should have routine mammograms every two years, instead of annually.
