Business is parting from its traditional allies in the Republican Party on healthcare as companies and big corporate lobbyists lend tentative support to a congressional overhaul. Republican lawmakers oppose the overhaul effort and call it a big-spending government intrusion. Many companies, on the other hand, cite soaring costs to explain why they continue to back the congressional work to revamp the healthcare system, despite misgivings over some provisions.
So much of swine flu preparation news has focused on how hospitals will cope with the pandemic that it was nice to see one organization, the American Hospital Association, sympathize with the challenges facing physician practices.
Since the spring H1N1 outbreak, the healthcare safety community has vigorously debated whether to protect healthcare workers with fit-tested N95 respirators or the more easily used surgical/procedure masks. A September 15 letter urging the CDC to quickly reverse the current recommendations favoring N95s placed the AHA firmly on the mask side of the argument, mainly for epidemiological and supply reasons. The AHA also observed that requiring respirators would give non-hospital settings, such as physician offices, which are unfamiliar with using fit-tested N95s, a disincentive to treat patients with flu-like symptoms, "resulting in a further surge of individuals being inappropriately sent to hospital emergency departments for care."
There is sort of a mild versus severe pandemic balancing act going on here. From the perspective of an outpatient facility, a mild case of H1N1 this winter could actually mean a strong surge for outpatient facilities and physician offices, as Paul Biddinger, MD, medical director for emergency preparedness and emergency physician at Massachusetts General Hospital in Boston, explained in the September issue of Medical Environment Update. "If the second wave [fall and winter] of H1N1 causes mostly mild illness, I think outpatient providers will feel the brunt of the surge of patients. If the virus causes more severe illness, it may be more in the emergency department and in the hospital setting."
But what if the CDC doesn't budge on the AHA's epidemiological and logistical reasons? A recent report by Institute of Medicine expressly favors fit-tested N95s, as do most healthcare worker labor unions and other healthcare professional associations.
Yes, physician offices are unfamiliar and confused about N95 fit testing, judging from calls received through the HCPro OSHA Hotline. Some think it is just a matter of showing workers how to put it on, pinch the metal bridge for the nose, and how to take it off. (See "Don't confuse N95 fit testing with user seal checking".
To hospitals, which regularly conduct fit testing, the N95 recommendation for H1N1 protection admittedly requires extra resources and time, but to the small physician practice, fit-testing probably seems like an insurmountable challenge, what with their lack of experience and expertise.
If you logically extend the AHA's argument, it appears that hospitals and physician practices are in this thing together, whether the CDC says yeah or nay to respirators. That's why the AHA might also recommend that its membership lend assistance to fit-testing staff members of physician practices in their community.
David LaHoda, the managing editor of Medical Environment Update and OSHA Watch, has produced healthcare training videos and consulted for medical practices and ambulatory healthcare facilities.
Bad news comes to those without health insurance. Individuals without private medical insurance are more likely to die, according to a new study, "Health Insurance and Mortality in US Adults," published in the September issue of the American Journal of Public Health.
In fact, they have a 40% higher risk of mortality when compared to people who have insurance, said researchers at The University of Washington School of Medicine in Seattle, and the Cambridge Health Alliance/Harvard Medical School in Boston.
Researchers surveyed 9,000 adults between the ages of 17-64, using nationally representative data from the CDC and the National Health and Nutrition Examination Survey. The study results confirmed their initial hypothesis that not having insurance is linked to mortality.
The latest numbers reiterate previous studies that date back to the 1980s, when researchers found the correlation between lack of coverage and death. Despite advances in medicine, those statistics haven't changed much.
Today, the current lack of health insurance is associated with nearly 45,000 deaths in the U.S., according to the study. With 46.3 million Americans lacking health insurance, according to the latest U.S. Census Bureau report, the link between "uninsurance" (as researchers call it) and mortality rates is suggesting there is a nationwide risk.
"What this study implies for those individuals [without insurance] and for our society as a whole, is that these are people who, because of their limited ability to access the healthcare system, have a higher risk of death," said Andrew P. Wilper, MD, MPH, lead study author and internal medicine physician at University of Washington School of Medicine. "They have a higher risk of not living as long as people who do find a way to find coverage."
Who are the underinsured?
The uninsured population are individuals without any type of healthcare cost coverage, as opposed to underinsured individuals who may receive limited care. The uninsured tends to be younger, poorer, and less educated, according to study results. In addition, those without coverage are traditionally minority (non-Caucasian) groups.
Has the economic downturn affected the number of people who can afford care? Unfortunately, it may have. The number of people without insurance rose by 600,000 in the last year, according to the census.
Most people receive health insurance through employment-sponsored coverage, so those who recently lost their jobs could be a greater risk for uninsurance and lack of care.
"People who are less likely to have work are also less likely to have a health policy," he said about his patients who have lost coverage from their work or state-level Medicaid programs. "Individuals without health insurance often delay care to their determinant. I've seen dramatic tragedies occur in people who have delayed care for very treatable illness."
"Individual physicians, hospital administrators—everyone's efforts make a difference. This is a society-wide problem that we have been unable to tackle for the last 100 years," Wilper said. "'How are we going to ensure that people in our society can have access to medical care?' is a political question."
Congress is expected to vote on the bill by year's end.
Karen M. Cheung is associate editor at HCPro, Inc., and blogger for HospitalistLeadership.com. She can be contacted at kcheung@hcpro.com.
One point of consistency in the healthcare reform debate has been the level of partisanship: When it comes to discussing or voting on issues, Democrats are siding with Democrats and Republicans are siding with Republicans. This has been underscored in Washington this week as hearings began on the Senate Finance Committee's healthcare reform bill—America's Healthy Futures Act of 2009.
So, when a group of more than two dozen senators representing both sides of the aisle come together on a healthcare issue and send a letter to President Obama—inarguably that's news. Just a week ago, 28 senators (20 Democrats, seven Republicans, and one independent) sent a letter to the White House asking the president—as he works with Congress on the passage of healthcare reform legislation—to emphasize that there is a need to "realign spending in the Medicare program to focus on providing more value to beneficiaries."
"We support many of the Medicare payment reforms that are included in current versions of health care reform legislation, but believe additional effort must be made to get better care at a lower cost," they wrote. In addition, they said that a fundamental way to improve Medicare's efficiency is to "realign the Medicare payment system to reward health care providers for the quality of care they deliver [and] not simply the quantity of services they provide."
Many of these senators were from so-called "high efficiency" areas—including Minnesota, Wisconsin, Utah, Vermont, New Hampshire, South Dakota, and North Dakota—that are known for using integrated health delivery systems and innovative quality measures "to provide Medicare beneficiaries with better value." Research shows, they said, that their states’ healthcare organizations' efficient delivery practices could save Medicare upward of $100 billion a year—while also providing beneficiaries better access to the care they need.
But what is behind that high efficiency? Mayo Clinic's CEO and President Denis Cortese, MD—whose institution has been frequently cited by President Obama for its quality of care and service delivery—noted that many institutions nationwide provide high-value care: care that produces better outcomes, better safety, and better service in comparison to the amount spent for it.
"What we really mean by healthcare reform is the healthcare delivery we are getting . . . healthcare that helps keep us out of the hospital, keeps us healthy, keeps us working, keeps us in school, and maybe helps prevent people with chronic illnesses or chronic conditions from long suffering," he told a Washington audience last week.
Among those institutions, regions, and those states that have high-value organizations, Cortese said they have a few common characteristics:
A higher level of a cultural focus is aimed at the needs of the patient. "There's more patient-centeredness thinking going on in those organizations or by those groups of providers that band together in communities or in states that have created better environments for caring for people," he said. "They are focused more on the patient."
A higher level of physician or provider engagement, leadership, and change is found among those taking care of patients. Specifically, a higher level of teamwork and collaboration is implemented when making medical decisions for patients.
A higher level of coordinated care is found where the teams use integration and coordination in managing the patients themselves. This can involve areas from how appointments are scheduled to are follow-ups.
A higher rate of sharing of medical records and information is found from one place to another. "With these galaxies of good delivery of high-value care, there's a fair bit more of connectivity about information than there is elsewhere," Cortese said.
Focus is placed on "the science of healthcare delivery." This means systemically looking at the ways patients flow through an organization—for instance, reviewing how certain processes can be done to reduce errors.
So, how does the country and all healthcare organizations get there? Cortese made a suggestion that it can start with Medicare as the country's largest payer—by paying for value. "The vision is to get there is a reasonable amount of time," he said.
And the country may be starting to point in that direction. Earlier this week, Senate Finance Chairman Max Baucus (D-MT) included an amendment in a modified version of his healthcare reform bill in which Medicare would place value of services over volume of service when paying for physician services. As proposed, Medicare under this amendment would begin paying for value beginning in 2015.
Cortese agreed that making a change to considering value can't happen all at once. "You can't jump a 40-foot chasm in two 20-foot steps," he said. Instead, it will take small steps—one after another—to make the big jump to value.
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A large number of U.S. medical schools say students have posted unprofessional material on Web sites such as MySpace, Facebook, and Twitter, but few schools have adequate policies in place for dealing with such behavior, a study found. Of 78 U.S. medical schools that responded to a survey, 60% reported incidents of students posting unprofessional content online, including material that was classified as profane, discriminatory, sexually suggestive, or violated patient confidentiality, according to the report.
The major obstacle to adopting evidence-based treatment guidelines may be patients, and Newsweek offers the example of a four-year-old with minor head trauma to illustrate the point. Research suggests that a head CT scan will not improve care in 99.9% of these cases, but most parents are concerned enough about the 0.1% chance to push for the test for their child.
During a pandemic, there is a high likelihood that staff members will not report to work for a variety of reasons. Some may contract the virus, others may have children or family members to care for, and others may require time off because of school closures.
Healthcare worker absenteeism can be detrimental to any facility, but for a small facility with few employees, it can be crippling. Unfortunately, absenteeism is also the toughest to plan for, says Terri Rebmann, PhD, RN, CIC, associate director for curricular affairs and assistant professor at the Institute for Biosecurity at Saint Louis University School of Public Health.
"The main thing is they should be talking about it now and trying to make some kind of plan, knowing there are going to be staff shortages," Rebmann says. "We already saw that before it was even deemed a pandemic, there were staffing shortages."
Rebmann suggests hiring contract workers or even retired healthcare professionals or medical students if the pandemic is bad enough.
Keep in mind that during a pandemic, healthcare workers that exhibit symptoms of influenza should remain at home. Rebmann says a big contributor to the SARS outbreak in 2003 was the fact that sick healthcare workers were still coming to work.
"[Healthcare facilities] need to be looking at their occupational health and sick leave policies to really make sure staff are able to call in sick with no repercussions," Rebmann says.
Plan for a surge of patients
Regardless of whether your facility will be hit hard by seasonal influenza or the H1N1 virus, even small medical facilities should have a detailed plan in place to handle a sudden or prolonged surge of patients.
Rebmann conducted a focus group on the H1N1 outbreaks among infection preventionists at the June Association for Professionals in Infection Control conference. Many of the pediatric facilities reported that their 24/7 hotline worked well to triage patients or provide care without bringing them into the facility.
"That at least reduced the number of people that would show up in the ED, because families would call in, talk to a healthcare provider on the phone, and decide 'yes, it's an emergency; I should go in,' or 'no, it's probably not; I can go see my physician or I can just stay home and not even require treatment,' " says Rebmann.
However, establishing this phone system is often cumbersome for smaller facilities with fewer resources. Directing patients to their local or state health department's phone line, which should be in place for providing guidance or answering questions, may be a better alternative. Other facilities that are part of a system may want to consider pooling their resources and placing one or two nurses on call for the entire system.
Screen patients for symptoms at the door
Many experts say the most important part of reducing the transmission of seasonal influenza and H1N1 is separating sick patients from well patients as soon as they enter the facility. To accomplish this requires two things: screening procedures and isolation precautions.
Rebmann notes that isolation precautions, especially those involving negative pressure, are extremely difficult in the limited space of an outpatient facility. Instead, the facility should plan on designating one or two rooms to place patients with influenza as soon as they enter the facility.
But to separate the sick from the well, you need to have screening measures in place. Screening techniques range from passive screening, such as placing a sign at the facility entrance that directs patients according to their symptoms, to active screening, which might include a brief medical exam.
However, actively screening patients requires resources, which is why many facilities are moving toward enlisting volunteers, student workers, or even security guards to perform basic assessments with the help of a simple checklist.
"We aren't talking about a medical evaluation, obviously," Rebmann says. "That's going to be done by the medical providers."
This article was adapted from one that originally appeared in the September 2009 issue of Medical Environment Update, an HCPro publication.
I have a confession: My first source of medical care for most non-emergency ailments isn't my primary care physician, a retail clinic, a physician assistant, or any other provider. It's the Internet. Before I even schedule an appointment with my doctor, I Google my symptoms to narrow down the list of possible ailments and decide whether I can wait out the problem or treat myself.
To be honest, my track record of self diagnosing isn't great, but I've gotten used to tracking down most of the information I need in daily life with a click of a mouse, and I take a similar approach to health issues.
I'm not alone, either. Nearly three-quarters of U.S. adults have searched health information online and two-thirds do so on a regular basis.
Ideally, these patients would be getting information from reputable sources and partnering with physicians to learn more about treatment options and even the science behind their conditions. If you haven't read this month's HealthLeaders magazine cover story about the patient of the future, I highly recommend it, because it presents a compelling vision for how physicians and digitally-empowered patients could work together in a future healthcare system.
Unfortunately, both the patient and the physician of the present are currently obstacles to that type of cooperation, in their own ways. Patients often frustrate physicians by obsessing over misleading information found online or ignoring advice about improving their own health. And physicians, accustomed to reverence for their expertise, don't always extend a hand to patients interested in their own care.
Adapting to the transformation of the traditionally compliant patient into the well-informed medical shopper will be one of the most significant challenges physicians face in the coming years, says Ed Millermaier, MD, MBA, the CMO and COO of Borgess Ambulatory Care in Kalamazoo, MI. Patients armed with clinical and practice information set higher expectations for their providers, and it can be tough to keep up.
To make matters more complicated, today's physicians have to meet the expectations of a growing segment of savvy patients while "continuing to meet the needs and demands of those who don't have this level of engagement in management of their own health," Millermaier says.
So what's a doctor to do? First, physicians have to move forward on electronic health record and other IT adoption. I've heard the arguments against adoption and understand the financial and practical objections, but it's difficult to imagine a patient-centered healthcare system in the future that relies on paper records. The case for delay becomes less compelling every day.
Physicians also need to redefine their relationships with patients. The cover story offers the example of Ken Davis, MD, a physician based in Conroe, TX. At the end of an appointment, he brings his patients into the hallway to a computer with Internet access, explains how to use MedScape, and provides a quick tutorial on how to find more information about the diagnosis. Taking a few minutes to do that saves him time, he says. A patient will come to the next appointment better informed and ready to work in partnership with the physician.
These changes aren't going to redefine healthcare overnight. But even if the ideal physician-patient relationship is never achieved, healthcare is shifting from a physician-centric to a patient-centric model, and physicians have to adapt.
Unfortunately, we are currently caught between the two models, so physicians have to keep a foot in both worlds to meet the demands of all their patients.
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Value over volume would come into play under a new Medicare physician payment system modification inserted into the Senate Finance Committee's healthcare reform bill this week.
Under the proposed physician payment change, backed by Sen. Maria Cantwell (D WA), physician or physician groups could receive bonus payments based on the relative quality of care they achieve while treating patients under the Medicare program.
Cantwell said in her opening remarks at the Senate Finance Committee's mark-up of the healthcare reform legislation that the fee-for-service formula used by Medicare to pay physicians "rewarded doctors for how many patients they see and how many procedures they order." However, physicians in her state, would receive lower payments because of the more cost-effective way they provided care.
Cantwell's proposal, now included in a revised draft of the legislation, would change the Medicare formula to pay providers nationwide based on a ratio of quality to cost—and not quantity. As written in the bill, this payment modification would take place in 2015—based on data obtained from a performance period the year before.
As proposed, the amendment calls for:
Using quality measures that factor in differences in the health of patients (such as age), and specifies that quality must be defined based on health outcomes—or the results physicians produce for patients.
Improving coordination and efficiency within the healthcare delivery system.
Taking into consideration special conditions for providers in rural or other underserved areas.
Cantwell had been working with Sen. Amy Klobuchar (D MN), who also had been calling for changing Medicare's payment structure. Last week, both senators were among 26 bipartisan senators who sent a letter to President Obama urging him to "realign spending in the Medicare program to focus on providing more value to beneficiaries."
Next time you watch your favorite TV show, you may see John D. Clarke, MD, FAAFP, rapping about flu prevention during the commercial break.
Clarke was announced this week as the winner of the Department of Health and Human Services' (HHS) Flu Prevention Public Service Announcement contest. One of more than 240 contest entries, Clarke's one-minute clip touches on the basics of infection prevention—namely by handwashing and practicing safe sneezing and coughing techniques. More than 50,000 people voted on the 12 finalist video clips in the competition.
"We are thrilled that so many Americans got involved in our PSA contest this summer," said HHS Secretary Kathleen Sebelius in a statement. "I want to congratulate Dr. Clarke, the 'hip hop doc,' for producing his creative and engaging video. His work will reach millions of Americans this flu season to remind them how to stay healthy."
Lines like:
If you think you're infected seek attention, if you have it stay at home so you don't spread none,
Use tissues when you sneeze because you could spread some, 'cause coughed up germs is where it spreads from
are sure to stick in the heads of adults and kids everywhere who need to remember certain basic actions to prevent the spread of the flu.
The Baldwin, NY, resident's rap mentions preventing the spread of H1N1, although the original competition was to promote certain practices for preventing spread of the seasonal flu. However, health officials expect the seasonal flu and H1N1 to together pack a decent sized punch—the WHO expects that within two years, one-third of the world's population will have caught the H1N1 virus.
Earlier this summer, HHS announced the competition and the entries started pouring in. Some used humor as a device for hitting the infection prevention message home, others relied on creative ways to display hygiene facts and good practices. Members of the public had 18 days to vote on their favorite clips at HHS' YouTube channel after a panel of judges from the video communications and public health industries narrowed the field down to 12.
Clarke will receive $2,500 for winning the competition.
