The American Medical Association's wobbly support of the healthcare reform effort is rooted in its attempt to find common ground among the increasingly splintered interests of the nation's 800,000 physicians. It stems, too, from differences in how the several bills before Congress deal with the amount the government pays them to treat older Americans, reports the Washington Post.
By more than doubling the maximum penalties that companies can apply to employees who flunk medical evaluations, healthcare reform provisions passed by the Senate finance and health committees could put workers under intense financial pressure to lose weight, stop smoking, or even lower their cholesterol. The bipartisan initiative builds on a trend that sees some employers offer lower premiums to workers who complete personal health assessments, while others limit coverage for smokers. But critics say employers could use the rewards and penalties to drive some workers out of their health plans.
House Speaker Nancy Pelosi warned insurance companies that healthcare reform could cost the industry dearly through new fees, fewer regulatory protections, and fresh competition from the federal government. The admonition came in response to the insurance's lobby's aggressive campaign to block reform legislation from advancing. Pelosi added that the House may adopt a Senate provision that would assess a flat fee on insurance companies that is expected to generate about $40 billion over 10 years as a way to pay for its reform bill.
Lakeside Medical Center in Belle Glade, FL, officially opened its doors on October 15. The 70-bed facility replaces Glades General Hospital, which served the community for more than 60 years. The $53 million facility was completed four months early and more than $6 million under budget, according to the Health Care District of Palm Beach County, FL.
Healthcare, like the rest of the United States, is transitioning from a service-based economy to an experience-based economy, said Joe Pine, best-selling author of The Experience Economy and Authenticity, during a keynote address at HealthLeaders Media 09: The Hospital of the Future Now in Chicago on Thursday.
Services in the United States have essentially become a commodity, he explained. The key to success for any business is not necessarily improving the service they provide, but improving the customer's overall experience. As an example in healthcare he pointed to North Hawaii Community Hospital, where every room looks out onto healing gardens and careful attention is paid to landscape and design. Although the gardens don't add a service in the economic sense, both patients and employees have better experiences because of them.
Fresno Surgery Center is also a leader in the experience economy, he said. The center spends five times the industry average on hospital food and other patient accommodations, which may not seem like a prudent financial move on paper. But a whopping 99% of patients rate their experience at Fresno as great on Press Ganey scores, and the additional investment is worthwhile, Pine said.
Although patient experience is receiving more attention in most hospitals, it isn't always perceived as a top financial priority. However, Pine made the case that improving patient experience is not only important to a hospital's bottom line, it is perhaps the single most important factor to success in the coming years.
Hospitals not only need to change how they operate, but how they invest and make strategic decisions, to succeed in the new economic environment.
Pine identified four priorities for hospitals to improve patient experience:
Theme the experience. Just as every hospital has a mission that guides its internal workings, every business should have an organizing principle for their customers' experiences, he said. Whether it is a children's hospital with baseball-themed patient rooms or Disney's sand-castle imaging machines, experience themes are pivotal to overall satisfaction and are the differentiators in today's economy.
Direct workers to act. "Work is theater, and every business is a stage," Pine said. Every worker, from the receptionist to the CEO, affects the patient experience, and each employee should know his or her part to play.
Mass customize offerings. Businesses need to learn how to customize customer experiences while staying efficient, he said. While each patient may receive a similar service, minor customizations can make the experience unique and more meaningful.
Go beyond experience. The next economic stage that Pine envisions is a "transformation" economy, in which businesses not only provide good experiences, but life-changing ones. Healthcare is perfectly suited for this model, and hospitals that are able to create a transformative connection with patients will win long-term loyalty, he said.
With tear-streaked cheeks, she reluctantly parted with her little girl. In a state of high anxiety she attempted to comprehend how exactly the mending and recovery process would take place.
And with patience and care, staff took the time to explain each step and, perhaps more importantly, make a real human connection.
Surely a positive outcome is what mattered most, but creating a memorable experience was the underlying goal of the employees at the American Girl Doll Hospital. And the little girl—a prized doll from the American Girl collection—turned out as good as new.
Gar Crispell, general manager for American Girl, shared this anecdote with us today on a panel of experts discussing the patient experience at HealthLeaders Media '09: The Hospital of the Future Now, a two-day leadership event in Chicago.
More than ever, healthcare organizations are trying to reinvent the patient experience—not just to see improvements to patient satisfaction scores, but also as a way of shifting the organizational culture to better meet quality and safety goals.
Although it's sometimes hard to do, it is important not to make assumptions about the girls and moms that come to the American Girl store, says Crispell. While the store's employees can't know what customers are thinking and feeling, they can always try to deliver a consistency and delight with every customer interaction, he says.
And similarly, real healthcare organizations can create memorable experiences for patients and family members that are only as good as the engagement levels of their employees. This reality presents a special challenge to senior leaders who want to change the perceptions of healthcare organizations as cold and emotionally sterile places of last resort.
With continual media coverage of gloom and doom stories of healthcare organizations and the industry as a whole, leaders need to keep fighting against negative perceptions, says Thomas Wright, president and CEO of Delnor-Community Hospital. Just as it is important to have systems in place to identify medical errors, Wright points out that hospital leaders should work to catch team members in the act of doing great things, recognize those extra efforts of employees living the values of the organization, and then share those stories with employees.
In just one of many examples that panelists shared with conference attendees, Wright told the story of a patient's mother who sought him out to thank him for the extra efforts by his staff to find a rag that had been tossed out as trash. This tattered cloth was a comfort to her disabled son who having surgery at the hospital, and she knew how much her son would need it after his procedure. Tearing up, she told Wright how committed the staff was to find this rag for her and her son.
Leaders who make the patient experience a priority for the organization and promote this type of story often help to create staff engagement that becomes part of the organization's culture, says Sonia Rhodes, vice president of customer strategy for Sharp HealthCare.
The San Diego health system has a program that Rhodes calls "first touch" in which employees try to establish a human connection with patients within the first three minutes of their interaction. She says that perhaps more important than sharing information with patients, it is essential to gather information that can help staff deliver a memorable experience. A great and unique patient experience will happen when team members can note something important about the patient, share it with other team members, and then act on it throughout the patient's interaction with the hospital, says Rhodes.
Efforts to enhance the patient experience can have detractors who cynically view such efforts as "flavor-of-the-month" programs that do little to improve healthcare outcomes. In particular, panel members noted that resistance by some physicians can be expected. Bridget Duffy, MD, principal at DS Health Care Consulting, says that when she was the chief experience officer of the Cleveland Clinic, a surgeon complained about the program by telling her that his patients should feel lucky to just be able to get up of the operating table and walk.
Duffy and Wright agree that leaders should never give up on engaging physicians in efforts to improve patient experiences. Wright says that his hospital's obstetricians were the first to participate in his program and, over time, medical staff members began to police each other's behaviors and promote Delnor's program.
"The person you least expect will rise up and become a champion," Wright says. "My biggest breakthrough was with a neurosurgeon who had been a frequent user of our physician disruption program." Wright says that through his hospital's ongoing patient experience program this highly engaged doctor eventually learned that he didn't have to be critical all the time and now this surgeon makes a point to often bring an OR nurse with him to have post-procedure discussions with patients and family members.
Rhodes says that the leadership at Sharp made a conscious choice to focus on employees first before engaging physicians so that they could see how the patient experience program improved the organization.
Aurelia Boyer, vice president and chief information officer for New York-Presbyterian Hospital says that including patient satisfaction data in the dashboard that hospital leadership reviews fortnightly also helps to move patient experience efforts forward because employees and physicians can see steady improvement over time. She also points that sharing health records with patients can not only enhance the experience, but it can also improve health literacy, coordination, and outcomes. "If people want to use PatientsLikeMe, we will help facilitate them into that new electronic world," says Boyer.
While Congress has focused on the estimated 46 million without insurance as it looks to overhaul the healthcare system, the House Energy and Commerce Subcommittee on Oversight and Investigations on Thursday moved to include review of the estimated 25 million who are underinsured.
Subcommittee Chairman Bart Stupak (D-MI) described "underinsured" as a person who "has health insurance coverage but the policy does not adequately cover healthcare costs or high medical expenses," he said. "Underinsured individuals traditionally have high out of pocket expenses because of high deductibles and copays."
Rep. Henry Waxman (D-CA), the Energy and Commerce chairman, said that in recent years, health policies have been costing more and covering less. "The average cost of a family's premiums has risen 131% in the last decade, while average wages have risen less than a third of that amount," he said.
The committee heard from several individuals who had been thrown into bankruptcy when their policies failed to adequately cover catastrophic illnesses.
Those who are underinsured have been steadily rising—up from about 16 million in 2003, said Sara Collins, vice president of The Commonwealth Fund. She told the panel that because of higher rates of chronic illness and poorer health, older adults between the ages 50 to 64 were the most likely of any age group to be underinsured; between 2003 and 2007, the share of older adults who were underinsured increased by 60%—from 11% to 18%.
She also reported that:
More than one quarter (26%) of underinsured adults had a deductible of $1,000 or higher compared to 8% of insured adults who were not underinsured.
Another 48% reported that their health plan placed limits on the total dollar amount their plan would pay for medical care each year compared with 36% of adults who were not underinsured.
Another 19% reported that their health plans limited the number of times per year that they could see physicians, excluding mental health visits, compared to 11% of adults who were not underinsured.
Collins also said that an estimated 72 million adults under age 65—both with and without health insurance—reported problems paying their medical bills in 2007, and 80 million reported a time that they did not get needed health care because of cost.
Waxman said that many of the "root causes" encountered by the underinsured would be addressed in HR 3200, the House's healthcare reform bill that is still under conference committee discussion. These areas include a ban on lifetime and annual caps on the amount insurers will pay; a ban on annual limits on total out of pocket costs; and removal of deductibles or copays for preventive care.
Cedars-Sinai CEO Tom Priselac Thursday listed four recommendations to improve the function of 64-slice CT scanners after 206 patients there received CT brain perfusion studies with eight times normal radiation.
In one of those recommendations, he suggested the machine's function may be improved with adjustments to the machine's auto function setting.
"Based on our understanding of the machine's auto functions, it should not have delivered an excessive dose. The auto function on CT scanners is used to provide the best quality of image using the lowest necessary dose," Priselac wrote in a two-page statement.
"We present this information not to shift responsibility, but to maximize patient safety by involving manufacturers in the process of continually improving processes and equipment," Priselac wrote.
The statement read: "The embedded default setting for image noise in the auto function in the 64-slice scanner, which was supplied by the manufacturer, did not match the manufacturer's recommended settings. The default applied by the machine in a CT brain perfusion scan is different from that applied during regular CT brain scan. As a result of the default's lower noise setting, the amount of radiation delivered was higher than expected."
According to the U.S. Food and Drug Administration, which, along with the California Department of Public Health is investigating the incident, the machine in use at Cedars Sinai is manufactured by GE Healthcare.
GE spokesman Arvind Gopalratnam said last week that "there were no malfunctions or defects in any of the GE Healthcare equipment involved in the incident" and emphasized that "patients and families should continue to have confidence in their doctor's recommendation for a CT scan."
Asked last night for additional comment after the release of Priselac's statement, Gopalratnam said, "Due to the pending investigation, we cannot comment right now. As the investigation progresses, we'll be able to share more in the future."
Priselac said the hospital wants to convey information "that we believe may be helpful to the FDA, scanner manufacturers and other hospitals in order to prevent this type of situation from occurring elsewhere."
In addition to adjusting the default settings, Priselac recommends that the FDA consider reviewing and revising the machinery's dose display, alerts, and forced functions and that there be additional password protections.
Dose Display: "The dose display on the screen of the scanner could be enhanced to facilitate ease of use by the technologists. This is especially true for time-sensitive scans such as CT brain perfusion, which is often performed urgently in the middle of a patient's stroke to determine the most appropriate treatment to preserve blood flow to the brain."
Alerts and forced functions: "Currently there is no forced function on the equipment requiring technologists to proceed with the scan only after confirming they have reviewed the appropriate dose. There could be more assertive audible or visual alerts on the scanners to indicate prior to scanning that the anticipated dose may be high."
Additional password protecting: "Certain settings on the equipment, particularly those with a high potential of resulting in an inappropriate level of radiation, should be password protected and only accessible for change by the manufacturer."
The problem with the 64-slice CT was noticed in August when a patient, who had previously received a scan, complained of patchy hair loss. When hospital officials looked through their records, they discovered 206 patients had received the scans over the previous 18 months. Of those, 40% who have been contacted also had patchy hair loss or reddening of skin believed to be linked to excessive radiation.
In his statement, Priselac said, "We take very seriously our responsibility for operating medical equipment in the safest possible manner, and deeply regret the circumstances that led to patients undergoing CT brain perfusion studies receiving a higher than appropriate level of radiation."
He said the dosage was "similar to the amount they might receive when undergoing a complex interventional procedure. We will continue to work with all affected patients to address any questions or concerns they may have."
Barry Pressman, MD, who chairs the hospital's Department of Imaging, said that the radiation "was higher than expected, but similar to an amount they might receive when undergoing a procedure such as angioplasty. As a physician speaking with patients, the goal is to address any side-effects that may occur, without unnecessarily alarming them, he said.
"In addition, our physicians addressed any concerns or questions the patients had, including questions from some patients about the radiation level," Pressman said. "We continue to respond to patients' questions and concerns. I sincerely regret if any patient feels they did not receive the information they needed."
Priselac, who also is this year's president of the American Hospital Association, said his hospital has made four changes as a result of its investigation.
They include "changes to assure proper validation of radiation levels at the time protocols are changed, improved access control over protocol changes and additional redundancy in the methods used to confirm radiation dose levels," according to Priselac.
The four changes are:
Protocol changes can only be initiated by Department of Imaging Section Chiefs, and must be clearly documented.
All changes will be reviewed by the radiation physicist to confirm they will not result in higher than appropriate doses.
After review and approval by the radiation physicist, authority to change standard protocol settings can only be updated in the scanners by the supervisor, and their ability to make setting changes is password protected.
In-service training for technologists on any changes to standard protocols and dose alerts will be expanded, and will be clearly documented.
Hospital officials also have not responded to questions about how they are following and monitoring the patients to determine whether they develop any conditions or diseases that may be linked to the overdoses.
Meanwhile, a spokeswoman for the FDA said Friday that "the FDA has not made a determination on the cause of this issue."
A total of 28,100 Connecticut residents will lose their health coverage in 2009 as a result of losing their jobs, according to an estimate by Families USA to be released in a report. By the end of the year, the consumer advocacy group projects that Connecticut will have 303,000, or 14.1% of all adults between the ages of 19 and 64 without healthcare benefits. That compares with 275,600, or 12.9%, in 2008.
Barry Dubin, who was selected as a $425-an-hour consultant for Miami-based Jackson Health System, has been linked to accusations of fraud in the closing of a Chicago window company. The case involves Republic Windows and Doors, where 200 employees made national newscasts when they refused to leave the plant for six days last December after the company lost its bank financing. After learning of the allegation, Jackson Chief Executive Eneida Roldan announced she had "formally requested that Mr. Barry Dubin be removed from the consulting team. This is no reflection on his expertise, but this has caused a distraction and we need to turn things around quickly. The hospital cannot afford this distraction."
