Hartford, CT-based Aetna has started a new online wellness initiative for international members, aimed at helping them achieve healthier lifestyles and cutting the insurer's cost for treating chronic diseases. The insurer also hopes the new program, The Wellness Checkpoint Health Risk Assessment, will allow it to distinguish itself in the international health insurance marketplace against bigger players, such as CIGNA, and foreign insurers.
Tennessee Gov. Phil Bredesen said that a healthcare reform proposal in the U.S. Senate could cost the state more than $730 million. The $900-billion, 10-year health reform measure seeks to expand health insurance coverage, impose new taxes and fees, and make major changes to Medicare and Medicaid. Bredesen estimated that the proposal would cost the state about $735 million over roughly five years, with a "range of about $570 million at the low end to $1.2 billion at the upper end."
Under a plan by California hospitals to access $2 billion in federal funds, a new "provider" fee would make them eligible for the money as subsidies for Medi-Cal, California's health insurance program for the poor. Hospital officials say existing reimbursement rates cover only a fraction of treatment costs, forcing some hospital networks and county-run facilities to absorb hundreds of millions of dollars in losses and leading more private providers to leave Medi-Cal. But fiscal conservatives are trying to persuade the governor to block the new levies on the institutions that want them.
Nearly 600 workers at Norwood (MA) Hospital will join the Service Employees International Union as the result of an election. Norwood became the third hospital in the Boston-based Caritas Christi Health Care system to unionize this year. The bargaining unit at Norwood Hospital will represent 594 respiratory therapists, radiology technicians, licensed practical nurses, nurse assistants, pharmacy technicians, paramedics, secretaries, housekeepers, dietary workers, and others.
With doctors treating more patients and hospitals facing pressure to be more efficient, companies like Apple Inc. and Research In Motion Ltd. see an opportunity. For example, Palo Alto, CA-based Stanford Hospital & Clinics started a trial with Apple and Epic Systems Corp., a provider of healthcare information systems, to test software that will let medical staff access patient charts on Apple's iPhone. Stanford is studying ways to use the devices to reduce the risk of error as patient care is increasingly handed off from one doctor to another.
It is hard to imagine a more uncertain time for the healthcare industry in the United States.
The recession has brought an increase in charity and unreimbursed care as millions of Americans join the ranks of the unemployed and lose their healthcare benefits. Recruiting in the midst of a severe physician shortage is only going to get tougher as more doctors retire and competition intensifies for the too-small candidate pool to replace them.
And, hanging over everything, is healthcare reform. Just about everyone agrees that President Barack Obama will sign some sort of healthcare reform bill this year. Few, however, would venture to guarantee what those reforms will contain beyond an expected expansion of health insurance coverage to some of the 46 million uninsured people in the United States.
So, physicians and other healthcare professionals are looking at a very distinct possibility that they will soon be asked to work harder for more people and probably not make as much money. A little anxiety and outright crankiness is to be expected.
"It's a very trying time for physicians. There are changes going on in the entire context of the healthcare delivery system, and the fact that the economy is down, and so their practices are down," says Jeff Peters, president and CEO of Surgical Directions, LLC, a physician-led consulting firm.
Peters says unhappy physicians should no longer be looked at as disgruntled prima donnas. "That is probably a dying concept. Clearly, the younger physicians are much more balanced and reasonable," he says. "The biggest issue is that they are working too hard. They have too many nights, too many weekends, too much call, and they aren't making enough money. So, there is a general unhappiness with the level of compensation in comparison to the amount of work they are doing."
Being human, Peters says, physicians will take their anger out on whoever is close to them, or whoever is perceived—whether fairly or not—to be the source of their frustration. And in a physician practice, no one is more of a lightening rod for complaints and dissatisfaction—even in the best of times—than the practice administrator.
Give physicians a say
"A lot of the other unhappiness stems from the doctor not making enough money. While the practice manager can't control the market forces, there is a lot they can do to drive the overall processes to help the practice be more successful," he says.
Peters says there are a number of big issues that can sink a physician practice if not correctly navigated. Probably the biggest single mistake a practice can make, Peters says, would be to change the compensation formula without input from the affected physicians. Billing and collections issues are always hazardous. The advent of electronic medical records (EMR)—which has the potential to profoundly reshape healthcare delivery—is another potential iceberg for physician practices. "There are going to be lots of changes associated with EMR, and it never goes perfectly, and they are going to blame the practice administrator," Peters says.
The best way to avoid friction with physicians is to involve them in the important decisions that affect the practice. With compensation, for example, Peters recommends creating a physician-led steering committee. "The administrator should provide the staff and support it and give them data but the ultimate decisions need to be made by the physicians," he says. "You can't just say 'be happy.' You have to create a model that allows them to constructively change how things are. Part of making them happy is to let them be responsible for things that they can control and drive."
In the case of EMR, Peters says it's imperative that operating processes are not changed before the EMR goes in. "You don't want to have an EMR and broken processes and no way to track what is going on in the practice with those broken processes," he says. "That is a good prescription for disaster."
Simplify as much as possible
Barbara Berry, senior director of planning and marketing at Northern Michigan Regional Hospital (NMRH), in Petoskey, MI, says the 243-bed, regional referral center for 22 counties has developed a management style that builds trust with physicians by clearing the hassles that distract physicians from their healing mission.
"You have to do what you say you're going to do, and you have to get the bureaucratic drag away from the physician. A practice manager or hospital administrator who can help dissolve and compress that decision-making cycle has the ability to win over physicians. Keep the noise away from them. They are here to practice medicine and take care of patients. Really, just make their life as simple as possible," says Berry.
Most recently, Berry and Peters helped nine NMRH-affiliated cardiologists change a practice business model that had been failing for two years. "A number of physicians had left the practice. They weren't able to recruit. Because the hospital depended on that practice as their largest service line, the market share was dropping," Peters says. "What the organization was able to do was acquire the practice, employ the physicians, and put in a new model for physician leadership, not just for the practice, but for the cardiology service line. And if you talked to each of the cardiologists, it has totally changed their lives."
Berry says the physicians' decision to change the business model was not pushed on them by hospital administrators, but was gently supported as the physicians realized their existing business model wasn't working. "It took 18 months, to where they had reached a point in their practice where they were pretty frustrated with their own inability to have a succession plan and then recruit," she says. "Knowing they were really the highest contributor to our revenue, it became an organizational strategic initiative to assist them."
Peters says the cardiologists went into the affiliation with NHRH assuming they would be hired into an employment model. "What was ultimately decided was we would create a cardiac institute where they would be a group but they would also have a role in co-managing the cardiovascular service line," he says. "They have really stepped up to the plate. The practice is doing better. They've made changes in how they cover their patients, how they interact with primary care physicians and with staff. There is a totally positive revamping."
The success, Berry says, came in part because the physicians and the hospital administrators were able to address key concerns around clinical technology and information sharing, and physician leadership. "Those are two areas that healthcare has danced around. This was explicit," Berry says. "This was a group of physicians that not only recognized they had some culture and leadership issues within the group and the service line, but they also agreed they needed some assistance with it. We hired outside consultants to help evaluate the past culture and identify dynamics of a future culture. And I have to applaud the physicians and the staff; they addressed those issues head on and they have made huge cultural changes."
Under the new affiliation, Berry says, the physicians are able to spend more time concentrating on healthcare, attending conferences, and reading, and are more open to interaction with colleagues and hospital administrators. "They really began to see the folks were there to assist and not to dictate. We have created a model that we originally didn't know would exist. We've all learned from it," Berry says.
Enjoy shared success
Berry says they've also gotten compliments from referring physicians. "They talk about the ease of access, the ease of patient information, the collegiality, the respect," she says. "The other piece is that we now have a hospitalist program that is working arm in arm with these cardiologists, whereas before there were episodes where they were adversarial."
Peters says he hopes he can help NMRH expand the model to other key service lines, like surgery, a driver for 65% of all hospitals' bottom lines. "There is always tension between the surgeons and the hospitals and there are complaints that the OR is mismanaged," Peters says. "That same leadership model works well in the OR. Where you put anesthesiologists and surgeons in charge of it by establishing a surgical services executive committee and let them co-manage the ER with a nursing director. You typically get improved surgeon satisfaction, a growth in volume, and improvement in OR profitability."
What should remain constant in any leadership model is giving the physicians as much support as possible to create an effective working environment. "What you do is try to put them in a position of leadership and then give them the tools so they can be successful," Peters says. "It's not treating them like children but treating them as adults and making them responsible but giving them the support they need to do what needs to be done."
The healthcare industry won't realize the full value of its investment in electronic health records until it finds secondary uses for all of the data being captured, such as predicting public health trends and improving patient care, according to a report by PricewaterhouseCoopers Health Industries Group.
Seventy-six percent of the more than 700 healthcare executives surveyed in June 2009 said that the information gathered in EHRs will be their organization's biggest asset in the next five years. But very few healthcare organizations are building systems and care delivery processes to effectively use the billions of gigabytes of data being collected.
"I'm surprised that more thought hasn't been given to the broader idea of using the clinical and administrative data to do continued improvement and process improvement in the industry," says Dan Garrett, head of the health IT practice at PricewaterhouseCoopers. "People are so busy doing the basic digitization of the whole industry that they haven't had time to think through what they will do with all of this data, and so it has not been taken into consideration in the deployment of some of these larger systems."
Healthcare executives should be thinking beyond implementing EHRs to how they want to use this data after the technology is in place. "If you know that you are going to try and aggregate the data and make statistical sense out of it, you are going to do it in a very different way than if you are designing a transactional CPOE," explains Garrett.
Unfortunately, there is no industry road map to follow. Instead healthcare providers are faced with three primary obstacles to the secondary use of data.
1. Data quality. Is there enough volume, depth, and breadth of data to produce statistically relevant information? For example, data that is aggregated from transactional-based systems like bill collection may not include clinically relevant information. In healthcare, after a bill is collected, "it is like that data is pushed off a cliff," says Garrett. He adds that in other industries—financial and hospitality—that doesn't happen. If people knew that data would be used by another physician, medical center, or research organization, systems would be designed differently and information would be captured differently, he says.
2. Workflow. Deciding when to physically interject that information into the clinical or administrative process is challenging, because it should be done at a point where it is relevant, the user can absorb it, and the user can take the appropriate action. "You are looking for impact, so you have to do it at the right point of the administrative and care delivery process," Garrett says.
3. Legal and policy concerns. Organizations are still struggling to determine when they can use this data and what are the liabilities associated with aggregated de-identified data. What if the data can be re-identified and traced back to patients? When can patients opt in and out?
Aetna, which gathers data from multiple sources to create comprehensive, personalized views of each of its members.
The American Heart Association/American Stroke Association, which has developed evidence-based guidelines for the treatment of cardiovascular disease and stroke based on hospital data.
Geisinger Health System, which created a company called MedMining that de-identifies and licenses its data for healthcare research.
Partners HealthCare, which uses data from its EHR to identify trends in drug usage based on post-market drug surveillance.
WellPoint, which piloted an integrated health record for its members that demonstrates how claims data can be used to support the delivery of care.
Key findings from the report include:
65% of health organizations expect their secondary data use to increase significantly within the next two years.
90% of executives said the industry needs better guidelines about how health information can be used and shared.
76% of executives said that national stewardship over, or responsibility for, the use of the health data should be regulated.
59% of organizations using secondary data have seen quality improvement.
42% of organizations using secondary data have achieved cost savings.
To truly achieve meaningful use, healthcare organizations will need to be able to move aggregated and non-aggregated data across the industry. In other industries those two elements are directly related, says Garrett, adding that if someone enters bad data, there are checks and balances in place to uncover the error. "As soon as healthcare delivery professionals personally experience what happens if they don't capture the right data, they will become that much more attentive to getting it right," he says.
Of course, providers will need to see the benefit to them on the backend before they'll devote the extra time and effort to capturing that clinically-rich data. That is why pilot studies will be a key element to moving the use of secondary data forward, says Garrett.
"If you see personal benefit, it takes on relevance and moves this off of the ‘that is great idea' quadrant."
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Nearly two-thirds of Massachusetts emergency physicians report more patients are seeking emergency care as result of state healthcare reforms, and nearly two-thirds of Massachusetts residents say their ED wait times have increased or remained the same, according to two polls released today by the American College of Emergency Physicians.
"This is clear evidence of what emergency physicians across the country have been warning—that universal health coverage alone will not solve the problems facing emergency patients," says ACEP President Angela Gardner, MD. "We support universal coverage, but national healthcare reform must address the severe problems facing the nation's emergency patients, such as dangerous delays in care."
In an ACEP Internet poll of 138 Massachusetts emergency physicians conducted last month, 51% of respondents report patient acuity levels have remained the same since the Massachusetts mandate went into effect. More than 20% of physicians report higher acuity levels, and more than 27% report lower acuity levels. In addition, 62% of emergency physicians said that "boarding"—or holding—admitted patients in emergency departments has increased or stayed the same since the Massachusetts mandate.
A separate ACEP-commissioned telephone survey of 1,002 healthcare consumers in Massachusetts, conducted last month by Harris Interactive, shows that 47% had been to an ED in the past year—either for themselves or with a family member. While 90% of Massachusetts residents with health insurance report being satisfied with their health insurance coverage, 84% say ED care should be a priority for healthcare reforms at the national level.
"The idea that emergency departments are filled with people who don't need to be there is simply not true, and these polls confirm that," Gardner says. "People will always need emergency care. The medical realities of a growing elderly population also tell us that."
David Blumenthal, the National Coordinator for Health IT, sent an open e-mail detailing the ongoing process for defining "meaningful use" of electronic health records. In his e-mail, Blumenthal offered a preview of what healthcare providers should expect from forthcoming meaningful use standards. He also described how the government plans to help hospitals and physicians transition to EHR systems.
Staffing needs will change after medical practices adopt electronic record systems, and a variety of factors will come into play. They include practice size, scope and, most importantly, the practice's goals. What happens in terms of the number of staff will largely depend on the problems the practice is looking to address with automation, notes this article published by the American Medical Association.
