Half of the board chairs of the nation's nonprofit hospitals said their boards don't rank clinical quality as one of their two highest priorities, according to results of a Harvard survey said to be the first of its kind.
However, chairs of boards that did prioritize quality oversaw hospitals that performed better on national Hospital Quality Alliance measurements than hospitals where boards didn't rank quality of highest importance.
"Most of them don't even prioritize it for evaluating their chief executive officers. They just don't think it's much of a priority," says Ashish K. Jha, associate professor in the Harvard School of Public Health.
The survey, conducted with co-author Arnold M. Epstein, chair of the Department of Health Policy and Management at the Harvard School of Public Health, is published in this week's journal Health Affairs.
The board chairs were asked to rank priorities from these six issues: quality, financial performance, operations, business strategy, patient satisfaction, and community benefit.
The authors see an association between these boards that are more engaged with the issue of quality at their hospital, and the likelihood that the hospital does well on quality measures. Likewise, they saw a link between hospitals where the boards didn't prioritize quality—and lower HQA scores.
"In high performing hospitals, boards are far more engaged, they know quality data, follow it closely, and think it's a high priority," Jha explains. "The boards ask 'how many patients did we harm last month? How many infections did we cause?' It may be that at high performing institutions, that sets the tone."
The authors concluded "this area represents a tempting target for intervention," however, added "the less than optimal focus on clinical quality . . . points to a difficult road ahead."
The researchers gathered 2007 national Hospital Quality Alliance scores for 3,410 nonprofit acute-care hospitals in three clinical conditions: acute myocardial infarction, congestive heart failure, and pneumonia. They then randomly selected 1,000 hospitals from this group, but oversampled those ranked in the top or bottom 10%, the high performing or low performing HAQ hospitals.
Board chairs of these 1,000 hospitals were asked to rank their top two priorities from those six issues. More than two-thirds, 722, responded.
Looking at the response rate for low-performing HAQ hospitals versus high-performing ones, there were significant differences, Jha says.
For example, among all hospital board chairs responding, only 44% said clinical quality was an issue considered in ranking a CEO's performance. But at low-performing hospitals, only 30% said it was a consideration while at high-performing HQA hospitals, 60% said it was considered.
Carlin Lockee, managing editor of the Governance Institute, which assists hospital boards, says she was surprised at the study's results. She says they differ from the Institute's similar surveys of nonprofit hospital CEOs.
"We have found more encouraging results," Lockee says. "And we believe that hospital boards still have a long way to go, but they have improved significantly over the last five years."
In fact, it's unclear whether the CEO in fact sets the tone, and not the board, and that those hospitals that perform better do so because they have better CEOs. It may not matter what the boards discuss on their agendas.
But Jha and Epstein say that their data "provide evidence of an association, although we cannot affirm a causal link" connecting boards that value quality with better hospital performance.
Among the survey's other findings:
Nearly three-fourths of board chairs of all hospitals responding reported that their boards have moderate or substantial expertise in quality of care. But high-performing hospitals reported a rate of 87%, compared to low-performing hospitals that had a 66%.
Only 20% of board chairs responding reported that the board chair, the board or one of the board's committees, was one of the two most influential quality forces at the hospital. Board chairs from high-performing hospitals were nearly four times as likely as those from low-performing hospitals to report that the board was influential.
More than two-thirds of board chairs reported being somewhat or very familiar with Joint Commission core measures or with HQA measures. But chairs of high-performing hospitals were far more likely than those from low-performing hospitals to say they were informed of those measures.
Quality performance was on the agenda at every board meeting in 63% of U.S. hospitals, and financial performance was always on the agenda in 93%.
Although emergency kits are designed to help nursing facilities provide medication to their residents during emergency situations, they can actually create more problems for facilities if not used properly.
Facilities must follow certain procedures and requirements to ensure their use of emergency kits is in compliance with federal and state law. Noncompliance could attract the attention of the Drug Enforcement Administration (DEA), which recently audited numerous long-term care pharmacies and facilities for noncompliance with Controlled Substances Act (CSA).
Emergency kits contain a small quantity of medications that can be dispensed when pharmacy services are not available. However, a nurse cannot simply remove a medication from the kit and administer it to a resident.
"In theory, if there is an emergency kit full of medications and a nurse gets an order from a physician to give a resident one of these medications, the nurse should be able to take the medication from the box and give it to the resident," says Carla McSpadden, RPh, CGP, assistant director of professional services at the American Society of Consultant Pharmacists. "But it doesn't work that way with controlled substances. When something comes out of that emergency pill box, it is the same as dispensing a drug from the pharmacy and, in order to dispense controlled substance, the pharmacy must have a complete prescription, not a just a chart order."
According to the DEA, a complete prescription for a controlled substance must include the following information:
Date of issue
Resident's name and address
Practitioner's name, address, and DEA registration number
Drug name
Drug strength
Dosage form
Quantity prescribed
Directions for use
Number of refills (if any) authorized
Manual signature of prescriber
"An emergency controlled substance prescription can be telephoned into a pharmacy, but the only person who can communicate the information to the pharmacy is the prescriber for class two drugs, and this must be done before a nurse could remove the drug from the emergency kit," McSpadden says. "The prescriber or prescriber's employee can communicate the information to the pharmacy for class three-five drugs."
Skilled Nursing Facilities and pharmacies also have to submit documentation when an emergency kit is used. Without a proper prescription or the necessary documentation, use of an emergency kit is considered in violation of the CSA, as is using emergency kits for anything other than emergency situations.
"A big problem we see is that these emergency kits often become mini-pharmacies and are used for regular, routine dispensing of controlled substances," says Mark Caverly, the head of the Liaison and Policy Section for the DEA's Office of Diversion Control. "As long as facilities use these kits only in true emergency situations, pursuant to a physician's proper authorization, the DEA has no problems with them.
One year after reporting that half of the nation's hospitals were running red ink, a new study released this morning finds that 80% of hospitals are back in black, with overall margins approaching levels not seen since the economy tanked.
"If they had a 401(k) statement to look at, it'd be lower than it was two years ago. But in terms of the operational financial statistics like margins and liquidity, it looks like hospitals in large part have returned to prerecession conditions," says Gary Pickens, chief research officer at the Center for Healthcare Improvement at Thomson Reuters, which produced the study.
"The market conditions have improved. Investment income is back. Hospitals no longer have to take realized losses. From a liquidity perspective, we have seen cash on hand rebound pretty substantially."
The study tracked 439 hospitals nationwide for key indicators, such as operating and total margins, reimbursement rates, patient volume, hospital employment and layoffs, and elective procedures through the second quarter of 2009.
The study found that:
Total operating margins grew from zero in the third quarter of 2008 to an average of 4% for all classes of hospitals in the second quarter of 2009.
20% of hospitals had negative profit margins in the second quarter of 2009; this is an improvement over the first quarter of 2009 when 30% of hospitals were operating with negative margins and the third quarter of 2008 when 50% of hospitals were operating in the red.
Hospitals' "median days cash on hand" increased from 90 days in the first quarter of 2009 to 150 days for the second quarter, which is higher than the historic long-term average.
While hospitals have maintained staff levels per occupied bed throughout the recession, total labor costs are down approximately 2.25% for the second quarter of 2009. This reduction in labor expense per discharge has been achieved by reduction of length of stay.
Mean patient discharge volumes for all hospitals that had trended down shortly after the beginning of the recession turned positive in the second quarter of 2009.
Pickens says he's been most impressed by hospitals' ability to manage expenses throughout the downturn, not necessarily through draconian reductions like layoffs but with a greater focus on efficiencies. "It seems like hospitals have risen to the challenge and have been able to manage their expenses effectively. Have they reduced salaries? No. Have they reduced the per-patient staffing? No. What they appear to have done is decrease length of stay by 2% to 3%," he says.
"It remains to be seen if that is an overall positive and sustainable with respect to quality. We have to look at make sure that hasn't resulted in a bounce back in the form of higher readmissions. But that appears to be one way they have been able to decrease labor expense, by managing patients in the hospital out more rapidly."
Pickens says hospitals have also lowered or at least stabilized drug expenses, and slowed the rate of increase for overall supplies expenses. "They have been able to keep those costs close to zero. It had been running 4% to 5% increases every year since 2005 when we began tracking this stuff in detail," he says.
Despite what appears to be a noteworthy turn-around, Pickens says there are still icebergs ahead. "We have to keep an eye on the really high unemployment rate and that looks like it hasn't peaked out yet," he says. "We've seen that there are increasing numbers of inpatient and outpatient services being paid for by government-sponsored rather than private insurance. The impact that could have on hospital payments is something we really need to keep an eye on."
Pickens says the Bureau of Labor Statistics' Hospital Producer Price Index also clearly shows that Medicaid reimbursement are going down in absolute numbers as cash-strapped states look for ways to cut expenditures.
"Hospitals have to continue to focus on the source of payment, especially if something looking like a public option emerges, or even worse, if things are allowed to continue as is and more people end up either uninsured or in the Medicaid/SCHIP extension rolls," he says.
Shortly before the clock ticked down to midnight, the House passed the healthcare reform bill (HR 3962) on Saturday by a narrow margin (220-215). Thirty-nine Democrats voted against the bill, while one Republican, Joseph Cao of Louisiana, voted for it. The bill's estimated cost is $1.1 trillion over the next 10 years.
House Speaker Nancy Pelosi (D-CA), after the vote, attributed the bill's passage in part to the "team" approach by House Democrats. She praised the three House committee chairmen—Henry Waxman (D-CA) of Energy and Commerce, George Miller (D-CA) of Education and Labor, and Charles Rangel (D-NY) of Ways and Means—who all had shepherded earlier the healthcare reform bill through their House panels.
She also thanked President Obama, who made a reform-related trip to Capitol Hill earlier in the day—telling those in attendance that now is the time "to finish the job."
"No bill can ever contain everything that everybody wants—or please every constituency and every district," the president said. "That's an impossible task. But, what is possible—what's in our grasp right now is the chance to prevent a future where every day 14,000 Americans continue to lose their healthcare insurance." The proposed bill has been projected to cover approximately 96% of Americans.
Conservative members from both sides of the aisle did join together over one issue prior to the vote on the Democratic healthcare bill: imposing tougher updated restrictions on abortion coverage. With a roll call vote (240 194), they cleared the way for conservative Democrats to back the overall reform bill. Also, a push by Republican members Saturday night for their alternative bill to reform was defeated 176 258.
In a statement after the vote, the American Medical Association's President James Rohack, MD, said that passage of the House health reform bill was "a big step forward as we work for comprehensive health reform this year."
Rohack added that the "bill will significantly expand health insurance coverage to Americans, empower patient and physician decision making, institute meaningful insurance market reforms, make substantial investments in quality, institute prevention and wellness initiatives, provide incentives to states that adopt certificate of merit and/or early offer liability reforms, and reduce administrative burdens."
Karen Ignagni, president and CEO of America's Health Insurance Plans, said in a statement, that "health plans strongly support comprehensive health care reform." However, she added that "the current House legislation fails to bend the health care cost curve and breaks the promise that those who like their current coverage can keep it" and that the public option included in the bill "will cause millions to lose their existing coverage."
One day after announcing the American Medical Association's support for two healthcare reform bills in the House, AMA President J. James Rohack, MD, told an audience of business executives that a failure to fix the sustainable growth rate formula could lead to a "crisis of access."
Speaking at the Harvard Business School Health Industry Alumni Conference, Rohack stressed the importance of H.R. 3961, a bill that eliminates the sustainable growth rate formula in Medicare that will mandate a 21% cut in reimbursements this January. Although another bill, H.R. 3962, contains the majority of proposed healthcare reform changes, passing one without the other would send mixed messages about reform, he said.
A similar bill to revamp the SGR formula failed in the Senate last month when legislators balked at its cost of more than $240 billion. Congress could have made the change years ago for a much smaller price tag, but each year the problem becomes more costly to fix, he said.
The SGR was implemented in 1997 with the intent of keeping physician payments from growing out of control by tying them to the growth of the overall economy. When the economy showed strong growth the first few years after the SGR passed, increases in payment per beneficiary kept up. However, as the economy slowed, healthcare costs continued to skyrocket, but the SGR system prevented physician payments from keeping pace.
The result has been a dramatic swing in practice economics. Physician payment has remained virtually unchanged, but practice costs have grown enough that physicians are already receiving nearly 20% less than they would have been if reimbursement levels weren't hindered by the SGR formula, Rohack said.
If another 21% payment cut is added to that in January, physicians might not only limit the number of Medicare patients they see, but many my choose to retire, he explained.
"Many physicians who are providing care to Medicare beneficiaries are 65 and older already. Once that stock market gets back to a particular level, and you got a 21% cut on top of 20% decrease already, you don't have to have a Harvard MBA to know that won't work."
Although the House is scheduled to take up H.R. 3961 soon, the Senate has not as of yet included a permanent repeal of the SGR formula in its healthcare reform legislation. Instead, the current Senate proposal would prevent the upcoming 21% payment cut from kicking in, leaving a longterm solution to be dealt with next year.
The House approvd a trillion-dollar healthcare package late Saturday that seeks to overhaul private insurance practices and guarantee comprehensive and affordable coverage to almost every American. The House legislation would for the first time require every individual to obtain insurance, and would require all but the smallest employers to provide coverage to their workers. It would also vastly expand Medicaid and create a new marketplace where people could obtain federal subsidies to buy insurance from private companies or from a new government-run insurance plan.
The White House is stepping up pressure on the Senate for quick action on healthcare reform, with President Obama calling on senators to "take up the baton and bring this effort to the finish line." President Obama's remarks came just 14 hours after the House narrowly approved a landmark plan that would cost $1.1 trillion over 10 years and extend insurance coverage to 36 million uninsured Americans. In the Senate, where proposals differ substantially from the House-passed measure on issues like a government-run plan and how to pay for coverage, the bill is stalled while budget analysts assess its overall costs, the New York Times reports.
As President Obama and Senate Democrats sought to generate momentum from the House's passage of healthcare legislation, a new hurdle emerged over profound dismay among abortion-rights supporters over antiabortion provisions inserted into the House bill, the Washington Post reports. The House passed its version of healthcare legislation by a vote of 220 to 215 after the approval of an amendment that would sharply restrict the availability of coverage for abortions, which many insurance plans now offer. The amendment goes beyond long-standing prohibitions against public funding for abortions, limiting abortion coverage even for women paying for it without government subsidies.
Lawmakers in the House voted 220 to 215 on Nov. 7 to approve a sweeping overhaul of the nation's healthcare system. Senate Democrats are still working to merge bills from two committees. Here, the New York Times provides a look at how the measures compare on some key issues.
President Barack Obama's healthcare overhaul faces an uncertain battle in the Senate after a narrow weekend victory in the House revealed the continuing divide among Democrats, the Wall Street Journal reports. Senate Democrats are struggling to agree on how to pay for the overhaul and whether to create a new public insurance plan to compete with private insurers, as the House did. Friction over how the bill treats abortion, which almost derailed the House vote, is likely to divide the Senate too.
