More people are going to the emergency rooms and many of them are elderly and often repeat users, according to a study published online today in the Annals of Emergency Medicine.
The study, "The Changing Profile of Patients Who Used Emergency Department Services in the U.S.: 1996-2005," found that patients using emergency rooms increased nearly 9% between 1996 and 2005.
The researchers wrote "EDs play a larger role in the management of geriatric patients over time. The increasing burden of the aging population in the EDs poses challenges in the training of future emergency physicians, care for older patients, public health insurance, and healthcare system reform."
"Growing numbers of elderly and chronically ill people are visiting the emergency department, and many of them are visiting multiple times in a year," said lead study author K. Tom Xu, PhD, of the Department of Family and Community Medicine at Texas Tech University Health Sciences Center in Lubbock, Texas. "Furthermore, patients who visit the ER three or more times a year increased 28% in just three years, from 1999 to 2002. We saw increases among blacks, the elderly, patients with two or more types of health insurance, and patients in poor health. There was a decrease in visits for the uninsured."
The number of non-institutionalized people who visited the ED increased from 34.2 million to 40.8 million, which represents 13.8% of the U.S. population, according to the researchers.
Researchers said the study shows that the common belief that the uninsured are flooding the country’s emergency rooms is not correct.
"Our study confirms that the poor and the uninsured are not the main contributing factors to emergency department crowding in recent years," said Xu. "The burden on emergency departments of caring for elderly patients has increased a lot in the last decade. Our aging population will create additional challenges in the training of future emergency physicians and in healthcare reform overall."
Because they found that the poor and uninsured are not the "main contributing factors for ED crowding," researchers suggested that future health policies that look to improve ED access for the poor and uninsured would have "limited effects."
"In contrast, better management of geriatric patients, who are likely to have a constellation of chronic disease, may produce better results. In terms of cost containment and disease management of patients, the relationship between primary and ED care perhaps is more similar to that between primary and specialist care than we previously thought, especially as the proportion of the elderly population in the U.S. increases. Ways to achieve efficient chronic disease management, disease prevention, and health promotion at the primary care level are critical in the pursuit of the solution for ED crowding and utilization," researchers wrote.
This increase in ED users could further complicate the issue of delays in EDs. Another study that appeared in Annals of Emergency Medicine earlier this week called "United States Emergency Department Performance on Wait Time and Length of Visit" found that only 30% of EDs got the majority of their patients seen by a physician within recommended time frames, and 13.8% of EDs achieved the triage target for the majority of patients who needed to be seen by a doctor within an hour.
Fifteen states could run out of hospital beds and another 12 states could reach or exceed 75% of their hospital bed capacity if 35% of Americans were to get sick from the H1N1 flu virus, according to a report released today by the Trust for America's Health.
In response to the outbreak, states and hospitals could cut the number of non-flu related discretionary hospitalizations, according to the TFAH researchers.
The new report, "H1N1 Challenges Ahead," based those numbers on estimates from the Centers for Disease Control and Prevention's FluSurge model.
"Health departments and communities around the country are racing against the clock as the pandemic unfolds," said Jeff Levi, PhD, executive director of TFAH, a nonprofit organization that promotes making disease prevention a national priority. "The country's much more prepared than we were a few short years ago for a pandemic, but there are some long-term underlying problems, which complicate response efforts, like surge capacity and the need to modernize core public health areas like communications and surveillance capabilities."
If 35% of Americans become sick with H1N1, the researchers said that Arizona, California, Connecticut, Delaware, Hawaii, Maryland, Massachusetts, Nevada, New Jersey, New York, Oregon, Rhode Island, Vermont, Virginia, and Washington would be at or exceed hospital bed capacity.
Twelve states would be between 75% and 99% of their hospital bed capacity: Colorado, Florida, Georgia, Maine, Michigan, New Hampshire, New Mexico, North Carolina, Pennsylvania, South Carolina, Utah, and Wisconsin.
The report suggests a number of short-term and long-term recommendations to address potential problems with H1N1.
Short-term recommendations
Refine plans for rapid distribution and administration of vaccinations
Reach out to encourage young adults, minorities, and other at-risk groups to get vaccinated
Enhance vaccine tracking systems to monitor adverse reactions
Improve payment system for vaccine administration
Develop and disseminate strong public messages about ways to practice proper hygiene and understand symptoms and remedies
Long-term recommendations
Establish more regional consortiums to organize and plan for public health emergencies
Recruit additional medically-trained staff for times of emergency
Create clear and practice plans to respond to emergencies or major influx of patients
Modernize U.S. disease surveillance systems
Modernize core public health infrastructure capabilities, such as technology and equipment to support core functions, including laboratory testing and communications
Revise pandemic plans continually
The Robert Wood Johnson Foundation supported the report through a grant.
Americans like to think that our healthcare quality is second to none. But how does the United States compare with other countries—particularly with our neighbor to the north: Canada?
A new review of the evidence on quality differences between the U.S. and Canada finds that each country performs better in different quality-related studies. But overall, the bulk of the research gives the edge to Canada, the researchers say. So how can this be?
Making the comparisons in the first place is challenging, according to one of the study's authors, Robert Berenson, MD, an institute fellow at the Urban Institute in Washington, DC. In looking at quality in the U.S., as compared to other countries, including Canada, "We found that the evidence was mixed as to where the U.S. stands on quality," he wrote in his blog.
"There was no objective evidence that the U.S. has the best quality in the world—although personal testimonials of exceptional care in particular circumstances should not be dismissed," Berenson said. "Overall, there is a lot of room for improvement [in the U.S.]."
Here's how it breaks down:
Overuse vs. Underuse. While only a small number of studies have compared the rates of overuse of health services, available evidence suggests that higher rates of certain surgeries and procedures in the United States "put more Americans at risk, in comparison with their counterparts," according to the study.
When the degree of variation among populations receiving particular services is greater than what would be expected, this raises a question on whether there is underuse of certain procedures in countries with relatively low rates or overuse in the countries with relatively high rates?
For example, several industrialized countries' rates of Caesarean sections per 100 live births range from 13.6% to 37.9%, with American rates among the highest. However, the World Health Organization has stated that rates above 15% offer no benefits in terms of population health.
Higher rates of surgery may have both a positive and negative impact of health outcomes, the researchers said. On one hand, the surgery could have positive benefits in terms of life expectancy and morbidity associated with the underlying condition. On the other hand, greater rates of heart surgery may contribute to the higher rates of mortality due to surgical and medical errors in the U.S.
Patient Safety. Problems with patient safety appear more prevalent in the U.S. However, few studies have compared patient safety at an international level. Available evidence, though, suggests that patients could be at greater risk of safety problems in the U.S. than elsewhere, including Canada.
Some international comparisons on mortality related to surgical and medical errors show that the U.S. has relatively high rates, in comparison with other countries. But the rates still could be problematic due to differences in reporting accuracy across countries.
Access Barriers and Uninsurance. Barriers to access that are encountered by those without health insurance raise another dilemma. Close to a fifth of the U.S. population under age 65 is uninsured. The U.S. is one of the few larger countries (with Mexico and Turkey), which have a sizeable share of their population lacking coverage. In Canada, coverage is universal.
Many of today's measures capture problems of "underuse" by the uninsured population—where they fail to receive the screening or treatment indicated, based on agreed medical practice standards.
Life Expectancy and Mortality. The U.S. is not among top performers in terms of life expectancy. However, the researchers note that this rate is influenced by factors both inside and outside the healthcare system.
While U.S. life expectancy is at or below average in comparison with other developed countries, the higher rates of death not related to healthcare (such as suicide or gun-related) show the United States to be among the worst performers.
Quality of Care for Chronic Conditions. Findings on the quality of U.S. care for several chronic conditions also provide a mixed picture. Among industrialized countries, the United States ranked below average in adult asthma care when looking at hospital admission rates and mortality rates.
When looking at outcomes related to patients with end stage renal disease, Canadians had longer survival times while in hemodialysis or peritoneal dialysis programs, and after receipt of kidney transplant—even when extensive adjustment for comorbidity is done.
In the long run, it appears that the U.S. is among the best in some areas, such as cancer outcomes, "and nowhere near the best in others, such as prevention, and deaths from preventable or manageable illnesses," Berenson said.
"In other words, we may do better when people are already quite sick: the U.S. seems to emphasize 'rescue care,'" he said. "But we are not doing well in helping people not to get so sick in the first place. Ultimately, our life expectancy is nowhere near stellar when compared to what other industrialized countries have achieved."
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Congress will pass healthcare reform legislation by the end of the year because Democrats fear the consequences that failure may bring, said Paul Begala, CNN commentator and former advisor to President Clinton at the 2009 Society Healthcare Strategy & Marketing Development conference in Orlando on Thursday.
"Democrats used to believe that if they exercised and ate right they'd have a job," he told the standing-room-only crowd. "The single biggest reason the healthcare bill is going to pass is because Democrats have the majority and the fear."
In addition to the Democratic majority on Capitol Hill, Obama has positioned the bill to pass by dividing his opponents and cutting deals with organizations like PhRMA and the AHA, Begala said.
He went on to say that Maine's Republican Sen. Olympia Snowe is the single most important person in the healthcare debate right now.
"Getting even one Republican may be the difference between healthcare and no healthcare," he said.
But he also cautioned that democrats shouldn't let a desire for perfection stand in the way of getting a bill passed—something he said he learned from his years with the Clinton administration.
"Don't let perfect be the enemy of good, don't let good be the enemy of OK, and don't let OK be the enemy of acceptable," he said.
Although President Barack Obama has said he wants a bill passed by Columbus Day, Begala said he believes it will pass closer to Christmas.
Effectively managing your service line requires not only an investment in developing a comprehensive system of care that engages all the key stakeholders, but also a commitment to continuously tracking, trending, and benchmarking your performance at the service line level. Outcomes management is an integral component of a destination center and acts as the driver for continuous performance improvement. Managing from metrics often separates the good from the great institutions.
To quote Peter Drucker, the man often credited with inventing modern management, "If you can't measure it, you can't manage it."
There are five key categories of measures you should be tracking:
Patient experience
Functional outcomes (i.e., post-surgical results)
Operational data (e.g., average length of stay [ALOS])
Clinical indicators (e.g., complications, range of motion, blood transfusion rates)
Financial data (e.g., contribution margins, market share)
In general, the traditional management model is weak at collecting and aggregating this data into a comprehensive service line dashboard that can easily be shared and understood.
Patient satisfaction is probably tracked most consistently because it has become essentially mandated by the government through financial incentives, has benchmarks for comparison, and is understood by most stakeholders. Unfortunately, in many institutions, patient satisfaction scores are not specific enough to lead to significant improvements.
They are often used as a grade to compare against other institutions rather than a tool to continuously improve. This is especially true if a hospital's percentile ranking is already high.
Surprisingly, hospitals often struggle to report service line data about costs, contribution margin, net margin, and market share. They, therefore, cannot effectively analyze differences in cost among physicians or other variables that might drive profitability; nor are they comfortable sharing this data with the physicians and staff who could help make important improvements.
Furthermore, without any benchmarking data for comparison, hospitals do not understand how well they are performing. This lack of transparency leads to problems when administration makes statements such as, "we are losing money on joints." Without supporting data or identification of the root causes, physicians assume that the statement must be false or that it's their colleague causing the problem—and trust is eroded.
Operational data such as LOS, discharge disposition, volume, and market share is often but not always available. The data is likewise not typically physician specific. Again, without benchmark data it is difficult for hospitals to understand whether their ALOS and discharge dispositions are consistent with practices at other institutions. The discrepancies in ALOS for joint replacement patients can vary from a low of 2.5 days to a high of 5 days. Discharge to home can vary from 10% home to 95%.
Clinical data such as complications, range of motion, distance walked, pain, and blood transfusion rates are rarely available. Although the data may be collected at the individual patient level, it is typically not aggregated in a way that can be tracked by facility or by physician. So if changes to protocols are made, there is no way to know whether changes were beneficial except by anecdotal means. The only clinical data that is consistently tracked and benchmarked for surgical procedures are process metrics such as use and timing of antibiotics (Surgical Care Improvement Project [SCIP] metrics), done so because the government has mandated or rewarded hospitals for measuring and aggregating such data.
However, with the advances in information technology and increased attention placed on data management, leading institutions are starting to redefine their approach to service line management by investing in developing service line–specific dashboards, identifying reliable benchmark comparisons, and sharing their results with a multidisciplinary team responsible and accountable for service line performance.
Electronic dashboards are now available that make it easy to track, trend, and benchmark service line performance a well as share it with key stakeholders.
Consider the following issues identified and resolved by five different hospitals using the same dashboard:
When one hospital uncovered significant differences in implant costs among five implant vendors, it shared that data with the surgeons to proactively discuss the need for consolidation.
Another hospital discovered a very high urinary tract infection rate for its joint patients compared to benchmark averages and began drilling down into the root causes.
A third hospital pinpointed major differences in reimbursement from private payers, including one that was reimbursing significantly less than direct costs. The hospital presented that data during renegotiations.
A fourth hospital identified a significant variance in average distance walked among its joint patients after surgery, which was adversely affecting ALOS, and tracked the problem back to the differences in treatments used for pain and nausea management.
A fifth hospital learned it had certain surgeons who were much more likely to discharge patients to skilled nursing or acute rehab, and discussed those findings in an effort to develop a more standardized discharge approach.
All of these examples highlight the value of managing service line performance with meaningful data and benchmarks as well as the potential impact on performance improvement. Destination centers must create a data-driven culture, institute accountability for performance, and reward service line managers for achieving superior performance.
Certain joint venture arrangements between physicians and hospitals may be illegal as of today. This is the day when changes to federal physician self-referral rules—Stark law—that limit specific financial relationships take effect.
You or someone at your practice should already know this—implementation of some components was delayed for a year when providers complained to CMS that they needed more time to restructure, or, in some cases eliminate, certain arrangements. If you weren't aware of the changes, stop reading right now and start reviewing your contracts.
Arrangements that will be affected include:
Per-click payments. CMS is tightening restrictions on per-click, or unit-of-service, payments for space and equipment leases. For example, a physician can't lease equipment to a hospital and receive a per-click fee each time a patient is referred to the hospital for a test.
Under arrangements. The target is physician-hospital joint ventures that allow physicians performing a service to receive higher compensation by contracting with a hospital to bill for the service. This is typically on an outpatient basis and was allowed previously because the definition of a designated health service was originally based on the entity that billed, rather than the one that performed, a service. Clinical labs or imaging services are sometimes contracted this way.
Percentage-based compensation. Physicians can still set up arrangements with hospitals for percentage-based compensation for professional services revenue they generate. However, they can no longer receive percentage-based payments for office space and equipment rentals or indirect compensation.
The new rules aren't drastically different—for the most part CMS was simply closing loopholes or expanding existing restrictions. But many physicians aren't happy with the changes. The American College of Cardiology and the American Medical Association have sent various letters to CMS asking the agency to alter the rules or at least delay implementation further.
While the rules don't outright restrict joint ventures and partnerships, they add to the administrative and regulatory hoops that physicians must jump through before they can partner with a hospital or just run a business.
Are the self-referral laws too restrictive? Many physicians would probably say yes.
The reasoning behind the original Stark law—to prohibit physicians from turning patients into profit centers by referring them to entities in which they have a financial interest—is fairly sound. Medicine is fundamentally different from most business ventures in that patient health and lives are at stake. The Hippocratic Oath by itself isn't enough to keep in check the potentially wayward invisible hand of profit-driven medicine.
But many physicians are small business owners and need to keep down costs and partner with other providers to make a living and provide quality care to their patients. Yet complying with Stark has become a game of cat and mouse, in which providers have to parse limited exceptions to the restrictions and continually revamp contracts in order to avoid becoming a criminal.
Stark law has been developed in three major phases, but there have been many more tweaks and changes over the years. Stark rules have popped up in the Inpatient Prospective Payment System, the Medicare Physician Fee Schedule, and in separate releases in the Federal Register. How is a physician supposed to follow along? The only real winners are the healthcare lawyers who interpret the regulations for a living.
I'm not suggesting we do away with Stark completely—self-referral deserves some attention. But as interest in hospital-physician partnerships has increased, it has become more difficult for them to work together.
Some simplification would help physicians and hospitals a lot.
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High courts in Georgia and Maryland will decide the fate of caps on noneconomic damages in medical liability cases in each state. The Georgia Supreme Court case stems from a February trial court decision rejecting the constitutionality of the state's $350,000 cap. Maryland's Court of Appeals is set to hear arguments on whether the state's caps apply only to cases that are arbitrated.
Wolfgang Bothe, CEO of Stonebranch, discusses the barriers to secure file transfer in physician practices and the possibility of physicians using mobile devices to interact with patients. [Sponsored by Emdeon]
The Joint Commission has released the 2010 National Patient Safety Goals (NPSG), announcing to the field a significant reduction in the number of requirements from the 2009 NPSGs.
The 2010 NPSGs for hospitals contain 11 requirements, down from 20 in the 2009 (the nine missing goals have not been removed; they are now regular standards instead.) There are no new NPSGs, although NPSGs 07.03.01, 07.04.01, and 07.05.01—which were phase-in goals during 2009 about preventing multiple drug-resistant organisms, central line-associated bloodstream infections, and surgical site infections—are now expected to be fully implemented and facilities will have to comply with them as of January 1, 2010. Additionally, many of the existing NPSGs contain significant changes for 2010.
"I really applaud the Joint Commission on making the changes they have," says Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor. "My perception is the NPSG are less prescriptive, clearer, and more manageable."
Medication reconciliation, NPSG 8, remains up in the air and a field review of the proposed revisions to the Goal are expected in the spring of 2010. The Joint Commission announced earlier this year that it would no longer cite facilities for failing to comply with NPSG 8 to "reduce the burden" on hospitals, although the Joint Commission has not removed the expectation that organizations comply with the Goal, which is still evaluated but "not scored" during surveys.
Some of the changes included in the 2010 NPSGs are effective immediately. These include any deleted requirements. Specifically, surveyors will not evaluate the following elements of performance for the remainder of 2009 (from the 2009 NPSGs):
NPSG.01.01.01, EP 1, concerning patient/family participation in identification prior to medication administration or treatment
NPSG.03.04.01, EP 7, concerning the holding of original medication containers
UP.01.01.01, EPs 1 and 2, concerning the pre-procedure verification process
UP.01.02.01, EPs 1- 3, and 7, concerning the marking of the surgical site
UP.01.03.01 EPs 1, 5, and 6, concerning performing a time out prior to surgery
Additionally, NPSG.07.02.01, which required organizations to consider a healthcare-acquired infection a sentinel event, was deleted because it was already covered in the sentinel event policy, and also will not be surveyed for the rest of 2009.
According to the October issue of Perspectives, the official newsletter of The Joint Commission, the requirements that were removed from the NPSGs and placed in the standards were done so to clarify where efforts should be spent. Once a requirement is moved to the standards, there's less of a need to spotlight the issue and less emphasis will be placed on it during survey.
Those 2009 requirements moved to the standards include:
NPSG.02.01.01 Verbal/telephone order, critical test result read back
NPSG.02.02.01 Do Not Use entries
NPSG.02.05.01 Handoff communication
NPSG.03.03.01 Look-alike/sound-alike medications list
NPSG.09.02.01 Falls
NPSG.13.01.01 Patient involvement in care
NPSG.16.01.01 Rapid response
Some of the EPs in the above listed standards were deleted upon their move to the standards.
"The release of the 2010 National Patient Safety Goals (NPSG) rolled back some of the difficult and unclear expectations introduced last year," says Bud Pate, REHS, vice president of content and development with The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. Pate points to changes, such as eliminating the need to designate an individual to participate in the identification process on behalf of a patient (NPSG.01.01.01) and the need for an immediate pre-transfer checklist process with the Universal Protocol (UP.01.01.01) as good developments with the 2010 NPSGs.
Also an oft-cited requirement (on 38% of 2009 survey reports), NPSG.02.03.01, concerning critical results, has been relaxed. The requirement to monitor critical tests is gone, and the remaining language is intended to allow more flexibility in the way that timeliness of critical result reporting is monitored. These are all positive changes, Pate says.
The revised language addressing the scope of the Universal Protocol has created some initial confusion: the protocol now applies to all invasive procedures, not just those that place the patient at risk.
"On its face, this appears to cover many procedures not currently subject to the time out (the only part of the Protocol that is not a natural part of the treatment process)," says Pate. "However, I also understand that the Joint Commission intends to ease back on the scope of the Universal Protocol. So we're hoping for further clarification."
Another significant change is clarification about the need for two time outs (UP.01.03.01). A second time out during the procedure is only required when the surgeon changes (removing the confusing language about when the procedure requires two consent forms). On the other hand, it now appears that a pre-anesthesia time out is always required. The field is also waiting for clarification about the time out for one-person procedure, says Pate.
In summary, the Joint Commission has taken a significant step back from what many hospitals believed, and had voiced to The Joint Commission, were needlessly prescriptive and impractical solutions to major safety concerns.
"However, as with any complex issue, there are a few 'devilish details' that are up in the air," says Pate.
To find the full version of the 2010 NPSGs, click here.
An amendment permitting health plans to reward healthy behaviors—one of the few bipartisan amendments introduced during the Senate Finance Committee hearings on healthcare reform—passed during late evening hours on Wednesday. The committee, which has several hundred more amendments to consider, has been working long hours to complete its reform measure in the next few days and to have legislation ready for the Senate floor by mid-October.
In a 18-4 vote, the panel agreed to a provision introduced by Sen. John Ensign (R-NV) and Sen. Thomas Carper (D-DE) that would add to a section in the updated Chairman's Mark to expand rewards that employers offer employees for improving their health. They called for increasing monetary rewards from 20% to 30% of the cost of an employee's coverage for participating in wellness programs.
"The key to achieving savings is to provide rewards for people who engage in healthy behaviors," Ensign said. The focus, though, "is on healthy behaviors and not genetics . . . we don't penalized people for any genetic problems they might have," he emphasized.
Both senators mentioned major companies—such as Safeway and Pitney-Bowes—that have used reward programs to keep their employee healthcare costs relatively stable. However, several senators, such as Sen. John Kerry (D-MA), expressed reservations that this type of provision could become a backdoor "vehicle for risk," in which individuals could be excluded from coverage because of various unhealthy behaviors.
Also getting the attention of the committee earlier in the day was an amendment that would require immigrants to present official photo identifications, such as drivers’ licenses, when signing up for public healthcare programs. Sen. Charles Grassley (R IA), who proposed the amendment, suggested that current law is too lax to prevent illegal immigrants from receiving government paid care.
At the current time, most newly arrived immigrants are ineligible for Medicaid or the state Children's Health Insurance Program (SCHIP) for five years, although they may obtain access to emergency Medicaid services. After five years, states may decide whether to cover the immigrants, but it must be verified if they legally are in the country.
"Shouldn't we care about people accessing thousands of dollars through identity theft," Grassley asked. "A stolen credit report has more than enough information."
However, several senators said much of the fraud related to Medicaid occurred from vendors or providers trying to beat the system. Sen. Robert Menendez (D-NJ) said that requiring ID would adversely impact the most vulnerable populations in the healthcare system—those who might be homeless or living in impoverished areas. The measure lost along party lines 13-10.
Sen. Orrin Hatch (R-UT) introduced two amendments pertaining to abortion. One amendment would require women to purchase a separate policy for abortion coverage under the bill; another called for stricter rules to protect those who worked at hospitals or provided other healthcare services if they declined to perform abortions for personal reasons. Both amendments failed by 13-10 votes.
