The chief executive of Cedars-Sinai Medical Center in Los Angeles said that he regretted the "circumstances" that subjected 206 patients to radiation overdoses and laid out reforms made since the hospital discovered that a CT scanner had been set erroneously for 18 months. In a written statement, Thomas M. 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."
The swine flu virus is spreading rapidly throughout California and Los Angeles, officials said. More than half of local health departments in the state are seeing active outbreaks, Mark Horton, MD, the state public health officer, said at a news conference.
More than 5% of patients going to doctor's offices have flu-like symptoms, which is much higher than the usual 2%, according to an estimate based on about 50 physicians across California who monitor flu activity for the state.
Labor groups criticized the Senate Finance Committee's healthcare plan as "deeply flawed" for its lack of a government-run option and its tax on expensive health-insurance plans. In ads in major newspapers, unions said a government-run plan is needed to provide competition for big insurers and keep costs down. The unions oppose taxing healthcare benefits because they fear the expense will be passed on to members who have forgone higher wages in return for richer healthcare packages.
At a time when Americans receive far more diagnostic radiation than ever before, two cases under scrutiny in California underscore the risks that powerful CT scans pose when used incorrectly. Cedars-Sinai Medical Center in Los Angeles recently disclosed that it had mistakenly administered up to eight times the normal radiation dose to 206 possible stroke victims over an 18-month period during a procedure intended to get clearer images of the brain. At Mad River Community Hospital in Arcata, the other case has led to the revocation of an X-ray technician's state license for subjecting the child to more than an hour of CT scans.
Physicians' organizations are mounting a concerted campaign to roust support for a newly introduced bill in the U.S. Senate that would do away with the Medicare physician fee schedule under the sustainable growth rate formula.
"This legislation is going to move very quickly, so we need to act now to ensure that it passes," says Lori Heim, MD, president of the American Academy of Family Physicians. "Senators need to hear from physicians today on the importance of voting in favor of each of these procedural votes. Healthcare reform really does require that we address the flawed current formula for Medicare payments. This would give us the basis for that fix."
Budgetary rules require Congress to offset any increased spending for healthcare reform. The so-called Medicare Physician Fairness Act of 2009, or S. 1776 would reset the SGR formula to zero and eliminate the $245 billion debt that has accumulated during the past six years as a result of Congress' annual fixes to ensure physician payments were not reduced. AAFP says resetting the SGR debt will allow Congress to establish a new payment system based on quality of care rather than the quantity of procedures or services.
"S. 1776 would mean that Congress can finally recognize that the annual overriding of the reductions that the badly designed (SGR) formula generates is simply postponing the needed replacement of the payment formula," AAFP wrote in a letter to members. "It is critically important for Congress to face this responsibility and pass S. 1776 this week."
Before the bill—sponsored by Sen. Debbie Stabenow, D-MI—can reach the Senate floor, it must have at least 60 votes on each of three procedural votes, with the first vote expected on Monday.
"We need 60 'aye' votes on each of these steps so the full Senate can take up this bill. Without this legislation, we won't have a permanent payment fix, and we're facing a 21% cut in Medicare payment at the end of the year," Heim says.
A permanent repeal provision is already included in the House health reform bill.
In addition, the American Medical Association announced that it plans to run nationwide television advertisements aimed at seniors and in support for S.1776.
The new TV spot features seniors and their physicians, while a voiceover says "every year Congress must make a temporary fix to the Medicare payment plan so seniors can keep their doctor and the care they depend on." The ad calls on the Senate to protect Medicare security and stability and repeal the SGR. It urges people to call their Senators to support S. 1776.
"Congress can no longer put a Band-Aid on the problem," says AMA President J. James Rohack, MD. "The 2009 Medicare Trustees' report projects payment cuts to physicians of about 40% over the next five years—forcing physicians to make tough decisions. Nearly 90% of people 50 and over are concerned that the current Medicare physician payment formula threatens their access to care. In just two years, the first wave of baby boomers will reach Medicare age."
Time constraints, financial pressures, and a waning sense of obligation to hospitals are hindering physician participation in hospital quality improvement efforts, according to a study by the Center for Studying Health System Change.
"Many physicians are spending less time in hospitals and increasingly are reticent about voluntarily giving their time to hospitals, so finding effective ways to engage physicians in quality improvement is an important challenge for hospitals," says Debra A. Draper, HSC associate director and a coauthor of the study. "While hospitals are making gains in quality, greater alignment of hospitals and physicians working together on quality improvement would likely spur considerably more improvement."
The study, Hospital Strategies to Engage Physicians in Quality Improvement, interviewed hospital leaders in Detroit, Memphis, Minneapolis-St. Paul, and Seattle, and identified strategies to involve physicians in quality improvement initiatives, including employing physicians; using credible data to identify areas needing improvement; providing visible hospital leadership support; identifying and nurturing physician champions to help engage their peers; and communicating the importance of physicians' contributions.
Hospitals historically have relied on the voluntary medical staff model to solicit physician participation—a model generally premised on a loose affiliation between hospitals and community-based physicians. However, as more services shift to outpatient settings and physicians confront quality-of-life issues and financial stresses, physicians feel less obligated to volunteer time for hospital activities, including quality improvement, according to the study, which was funded by the Robert Wood Johnson Foundation.
The study also found that:
While respondents often described medical staff bylaws as encouraging physicians to "be good citizens" and participate in quality improvement activities, bylaws often lack the specificity or accountability that clearly outline physicians' responsibilities.
Hospital employment of physicians is becoming more common, often as part of a larger set of alignment strategies, such as securing emergency call coverage and initiating new service lines to attract patients. Typically, quality improvement is not the main reason driving tighter alignment of physicians and hospitals, but employment can create incentives for physician involvement in quality improvement by lessening competing pressures on physicians' time and increasing physician accessibility and visibility in the hospital.
Credible data to identify areas that need improvement and systematically assess progress are essential to securing physician participation in hospital quality improvement. Many respondents recounted how physicians assume they are providing good quality of care until they are shown data proving otherwise.
Visible commitment by hospital leadership can foster physician involvement in quality improvement activities. An important role of hospital leadership is creating a strong quality culture by publicly demonstrating that quality improvement is important, supported, and encouraged.
Physician involvement in quality improvement reportedly is often limited to a fraction of the active medical staff. Finding ways to engage more physicians is critical to quality improvement, which ultimately requires all members of the medical staff to adopt process and practice changes.
In soliciting physician involvement in quality improvement, hospital leaders reported the importance of clear communications. Respondents believe that showing physicians that quality improvement activities improve patient outcomes and aren't just administrative or regulatory requirements increases their willingness to participate.
To identify and promote quality improvement measures, the study recommends that the nation's healthcare quality improvement agenda should consider:
Rationalizing the demands placed on hospitals and physicians, focusing on a limited number of quality improvement initiatives that demonstrate the most promise for significant improvement, and striving for consistency across programs;
Creating mechanisms to assist hospitals to use data to improve patient care quality, such as centralized data repositories
Establishing financial and other incentives to support hospital quality improvement while also examining state and federal regulations, such as gain-sharing prohibitions, that may impede hospitals' engagement of physicians in quality improvement.
The Commonwealth Fund's 2009 State Scorecard on Health System Performance—much like its inaugural version in 2007—finds a mixed bag in terms of quality healthcare. On one hand are deteriorating health insurance coverage for many adults and rising healthcare costs, but on the other hand there are signs of improved quality of care processes and better coverage of children. However, each state has its own story to tell.
"Where you live really does matter in terms of your ability to access the healthcare system and the quality that you receive," said Rachel Nuzum, senior policy director with the Commonwealth Fund's Washington office. "We've seen that wide variation continues to exist between the states in terms of the top performers and the lower performers. And, the gap is growing."
The scorecard looked at all states using four major categories:
Access to care (by both children and adults)
Prevention and treatment (including screening and preventive care, surgical infections, and provider interactions)
Avoidable hospital use and costs (including pediatric admissions and short-stay nursing home residents with hospital readmissions within 30 days)
Healthy lives (including mortality rates, adults who smoke, and children who are obese)
"Sometimes there is much as a two- to three-fold spread between the top and bottom states," Nuzum said. "That's a huge difference." Most of these difference occurred in the areas of access and quality.
Similar to two years ago, nearly the same 13 states rose to the top quartile and outperformed their peers on multiple indicators: Vermont, Hawaii, Iowa, Minnesota, Maine, New Hampshire, Massachusetts, Connecticut, North Dakota, Wisconsin, Rhode Island, South Dakota, and Nebraska. Many of these states have been leaders in reforming and improving their health systems—for example, by targeting efforts to reduce rates of uninsured adults and children, the report noted.
Ten of the 13 states in the lowest quartile of performance—Tennessee, Alabama, Florida, Kentucky, Texas, Nevada, Arkansas, Louisiana, Oklahoma, and Mississippi—also ranked in the bottom quartile in the 2007 State Scorecard. Three other states—North Carolina, Illinois, and New Mexico—descended from the third quartile, while California, West Virginia,and Georgia moved up out of the last quartile. Rates of uninsured adults and children were on average double those in the top quartile of states.
Among the states that moved up the most in the overall performance rankings, Minnesota rose within the top quartile to become the fourth ranked state, showing significant improvement on multiple indicators. Three states: Arkansas, Delaware, and West Virginia, plus the District of Columbia—had at least half of their performance indicators improve by 5%.
Some of the leading states set new benchmarks for 20 of the 35 indicators with trends. These patterns indicated that public policies at the state and local levels could make a difference, according to the report. Vermont, Maine, and Massachusetts, for example, have enacted comprehensive reforms to expand coverage.
And Minnesota proved to be a leader in bringing together public- and private sector stakeholders in collaborative initiatives to improve the overall value of healthcare, Nuzum said. This is an approach that appears to be gaining ground in other states.
Other highlights of the report:
The quality of hospital care for heart attack, heart failure, pneumonia, and the prevention of surgical complications improved sharply, as all states gained ground and the variation across states narrowed. The improvement takes into account the impact of national efforts by Medicare to measure and benchmark performance.
Key indicators of nursing home and home healthcare quality improved in nearly all states, with declines in rates of pressure ulcers, physical restraints, and pain for nursing home residents and improved mobility for home care patients.
Ambulatory care quality indicators, including preventive care, changed little or declined in half the states, with wide gaps persisting across states.
In many states, symptoms of poor care coordination and continued inefficiency in the use of resources are evident in the increasing rates of hospital readmissions.
And, in most states, increases in hospital admissions have occurred and readmissions from nursing homes, as well as hospital admissions for home healthcare patients. These indicators point to a lack of incentives for effective transitional care and care management, the report noted.
"There's been a lot of talk of international models. We think there is a lot of value to that. But at the same time, we know we're in a kind of uniquely American situation here with the way that our system is constructed," Nuzum said. "And some really innovative creative things are happening at the state level."
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California Governor Arnold Schwarzenegger signed legislation October 11 requiring California nursing homes certified by Medicare or Medicaid to post their rating determined by CMS' Five-Star Quality Rating System. The bill, known as Assembly Bill 215, will go into effect January 1, 2011.
The Five-Star Quality Rating System, which was launched in December 2008, uses data from nursing home surveys, staffing rates, and 10 quality measures to calculate star ratings, ranging from one to five.
The new legislation requires Medicare or Medicaid certified nursing homes in the state of California to post their overall star rating information in at least the following locations:
An area accessible and visible to the public
An area used for employee breaks
An area used by residents for communal functions and activities
The information, which should be posted on white or light-colored piece paper, must include the following, in the following order:
The full name of the facility, in a clear and easy to read font of at least 28 point.
The full address of the facility, in a clear and easy to read font of at least 20 point.
The facility's most recent overall rating determined by CMS' Five-Star Quality Rating System. This information should be in the center of the page, in the form of the number reflecting the rating, and in a clear and easy to read font of at least two inches. A facility will have seven business days from the day it receives a new rating to post it.
Below the star rating should be "The above number is out of 5 stars" in a clear and easy to read font of at least 28 point.
Although Assembly Bill 215 is an effort to educate consumers about facilities' quality of care ratings, many providers, associations, and other professionals in the long-term care industry are not thrilled that this legislation has passed.
According to a representative from the American Health Care Association (AHCA), "AHCA believes that reliably and accurately measuring quality, and publicly disclosing the results, will help to inform consumers' health care choices, especially in identifying care facilities that best meet individual needs. Since we believe that CMS' Five-Star Rating System fails to provide the tools necessary to evaluate quality care and may do more to confuse and even mislead consumers than to enlighten them, we oppose the notion that facilities should post these ratings."
The legislation also requires nursing homes to provide consumers with a detailed explanation of their rating as well as how to access this information on the Nursing Home Compare Web site. Failure to comply with the provisions of this legislation will result in a class B violation, the fines from which will be deposited into the State Health Facilities Citation Penalties Account.
Between aging Baby Boomers and obesity in school children, there appears to be no shortage of work for dietitians in the coming years. However, hospitals may need to take a closer look at how these employees write diet orders in order to comply with national regulations.
In 2008, word spread among registered dietitians (RD) that CMS was citing hospitals that allowed RDs to prescribe diet orders. The therapeutic diet regulation that required diet orders to be prescribed by the patient's practitioner (i.e., a licensed independent practitioner [LIP]), had been on the books since 1986. It wasn't until October 2008, when the issue was featured in the Medicare State Operations Manual Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals, that surveyors began strongly enforcing the regulation.
However, some in the California dietitian community believed this regulation was unduly restrictive and slowed patient care. Some RDs successfully petitioned their medical staffs to grant them privileges so that they could write their own diet orders. When the state department of public health surveyed these organizations, they faulted them for privileging a non-LIP practitioner.
Today, California RDs continue to seek clinical privileges, along with an LIP status that would ease the path to their primary goal. Because the CMS regulation affects RDs nationwide, other states are likely to face similar hurdles.
Mary Hager, PhD, RD, FADA, director of regulatory affairs in the ADA's Washington, DC, office, says the organization supports the efforts of RDs nationwide to gain clinical privileges so facilities can privilege those who qualify to write diet orders.
"The pursuit and development of such advance skills also raises some legal considerations that must be addressed in the context of the broad range of patient care for which, in virtually every aspect, the physician practitioner is legally accountable," Hager says. "The diet order and related orders are the specific legal responsibility of the medical practitioners—namely medical doctors and doctors of osteopathic medicine—and their delegation to other providers does not eliminate that responsibility."
Heidi Kiehl, MS, RD, CNSC, member of the professional practice task force of the California Dietetic Association's (CDA) public policy counsel, says the CDA became aware of CMS' diet order rules after RDs in the field approached the CDA with questions. When CMS began telling RDs they needed privileges to practice, the RDs weren't familiar with the regulatory terminology. "It was like a foreign language to us a couple of years ago," says Kiehl.
The CDA plans to rewrite its business and professions code and address licensure to make changes. To achieve that goal, CDA is working with a healthcare lawyer specializing in scope of practice and the organization maintains a working relationship with the Department of Public Health.
"We're also working with the American Dietetic Association, who has a licensing work group to help states that don't have licensure," says Kiehl. "We're not the only state that doesn't have licensure for dietitians, so there's a cluster of us who are working to move this."
Emily Berry is an associate editor for Briefings on Credentialing and Credentialing Resource Center Connection, and manages CredentialingResourceCenter.com. You can reach her at eberry@hcpro.com.
There are plenty of reasons to be pessimistic about the future of healthcare, and I've heard many of them this week. I have been in Denver at the MGMA annual conference, and almost every general session I attended started with a similar litany of statistics about the major problems with the U.S. healthcare system. To sum up dozens of charts and graphs in one sentence: We pay much more than anyone else in the world for healthcare, but don't get better quality as a result.
The bad economy has added salt to the system's wounds. I wrote last week about a survey showing medical group revenues dropping for the first time in years. On top of that, physicians are facing a potential 21% cut in Medicare reimbursements if Congress doesn't intervene by the end of the year, as well as Medicaid cuts in several states.
Yet, William F. Jessee, president and CEO of MGMA, told attendees during his keynote address earlier this week that despite all of the challenges, he remained optimistic about the future of healthcare. Here are a few of his reasons for optimism, and a few of mine:
1. Healthcare IT is improving. Several times during the conference, Jessee used an anecdote familiar to anyone who has been following healthcare IT and EHR adoption efforts. You can swipe a debit card almost anywhere in the world and instantly receive balance information and make a withdrawal in the local currency, he explained. But if someone was unfortunate enough to was seriously injured after being hit by a car while walking down the street in Denver, the physicians at Denver Health most likely couldn't pull the person's health information, even if his or her primary care physician was located less than a mile away.
Certainly, there is a long road ahead to EHR adoption, but a lot of progress is being made in other areas of health IT. Practices are innovating with e-prescribing, online patient visits, telemedicine, and a wide range of other technologies that improve healthcare delivery. And despite questions about meaningful use and concerns about HITECH penalties, the potential for up to $44,000 in stimulus reimbursement for implementing an EHR system should ease physicians' reservations about adoption, if only a little.
2. Administrative costs are getting attention.As I wrote earlier this week, there are several provisions in healthcare reform bills that could streamline healthcare administration and save billions. Machine-readable ID cards, electronic claims attachments, standard insurance operating rules, and other changes could reduce management headaches and cut practice overhead for a lot of doctors.
Even in the private sector, more attention is being paid to excessive administrative costs. America's Health Insurance Plans, Blue Cross and Blue Shield Association, eight health insurers, and five Ohio physician organizations will begin a pilot project next month that will look to reduce health insurance paperwork and ease physicians' administrative hassles. The project will create a one-stop Web portal in Ohio for electronic transactions, and 91% residents insured through private carriers will be part of the project.
3. Payment reform is a reality. Don't worry about the proposed 21% Medicare reimbursement cut scheduled for 2010. It won't go through. At worst, Congress will apply another Band-Aid and replace it with a 0.5% cut or something in that range. But even better, healthcare reform legislation may finally repeal the flawed Sustainable Growth Rate formula that puts physicians in this position every year.
There are other positive signs in the reform legislation: Primary care payment increases are being proposed, as are incentives for advanced medical homes and other projects that reward coordination and quality. Progress is being made outside of Washington, as well. Private payers are taking initiative with payment demonstration projects, and pay-for-performance programs are slowly moving beyond merely paying for reporting.
4. Leadership makes a difference. Today and tomorrow I'll be in Chicago with some of my HealthLeaders Media colleagues who are presenting this year's Top Leadership Teams in Healthcare awards. Winners come from a wide range of settings—from large hospitals to medical groups—but each demonstrates that the obstacles of today's healthcare system can be overcome.
There is a lot of defeatism about the healthcare environment, but providers' fates are still largely in their own hands.
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