One day after physicians suffered a pair of setbacks in a healthcare bill unveiled by Sen. Max Baucus, President Obama moved to ease the pain by accelerating a $25 million program aimed at softening the pinch of medical malpractice lawsuits. For months Obama has wooed the nation's doctors and it appeared the courtship was paying off. But tensions flared again this week when doctors discovered that the Baucus bill does nothing substantively to address malpractice costs and offers them only modest gains on the high-priority issue of Medicare reimbursement.
House Speaker Nancy Pelosi said that she worries that the protests over President Obama's healthcare legislation may resemble the anti-gay rhetoric of the late 1970s in San Francisco, which culminated in the assassination of two of her hometown's political leaders. Pelosi, responding to a question about anti-Obama sentiment, said partisans on all sides have the right to voice their opinions, but she has concerns about some of the language that is being used.
After months in which the White House had seemed to ignore liberals as it courted centrists to join the president's signature cause, liberal lawmakers have finally attracted the administration's attention. They, in turn, have to decide how far to press their case. Compared with the Baucus bill, a liberal package would include more generous subsidies for working-class families and small businesses to buy coverage.
Senators of both parties said that they would seek significant changes in a Democratic proposal to tax generous high-cost health insurance policies. The tax, proposed as a way to help finance coverage of the uninsured, would be levied on insurance companies. But the senators said they worried that it would be passed on to individual policyholders, families, and employers who buy insurance for their workers.
In the ongoing healthcare reform debate, one issue seems to hover over the discussion—but is rarely addressed: Is the inability to obtain health insurance associated with a higher probability of death?
A new Harvard University Medical School study brings the topic out into the open by linking nearly 45,000 deaths each year to the lack of health insurance.
The grim new figure is about two and a half times higher than those in a 2002 estimate from the Institute of Medicine, and—if accurate makes a lack of health insurance more deadly than common killers such as kidney disease.
The study found that uninsured, working age Americans have a 40% higher risk of death than their privately insured counterparts, up from a 25% excess death rate found in 1993. Health Insurance and Mortality in U.S. Adults appears in today's online edition of the American Journal of Public Health.
"Limited access to primary or preventative care likely does explain a lot of this," said Andrew Wilper, MD, the lead author of the study, who teaches at the University of Washington Medical School. "We doctors have many new ways to prevent deaths from hypertension, diabetes and heart disease but only if patients can get into our offices and afford their medications."
The study analyzed data from national surveys carried out by the Centers for Disease Control and Prevention. It estimated that lack of health insurance causes 44,789 excess deaths annually. Previous estimates from the IOM and others had put that figure near 18,000. The methods used in the current study were similar to those employed by the IOM in 2002.
Wilper said the study's findings can't be attributed simply to low socioeconomic status. "That is a question we try to answer in the study. We include in our analysis not only income levels but health behaviors, exercise habits, smoking, drinking alcohol."
“No study is perfect," he added, "but we tried to control for those other factors that might be alternate explanations for the findings. All other things being equal, including income, these findings appear to be true."
An increase in the number of uninsured–and an eroding medical safety net for the disadvantaged—likely explain the substantial increase in the number of deaths associated with lack of insurance. Another factor contributing to the widening gap in the risk of death between those who have insurance and those who don't is the improved quality of care for those who can get it.
The research, carried out at the Cambridge Health Alliance and Harvard Medical School, analyzed U.S. adults under age 65 who participated in the annual National Health and Nutrition Examination Surveys between 1986 and 1994. Respondents first answered detailed questions about their socioeconomic status and health and were then examined by physicians. The CDC tracked study participants to see who died by 2000.
"The uninsured have a higher risk of death when compared to the privately insured, even after taking into account socioeconomics, health behaviors and baseline health," Wilper says. "There are always issues in these retrospective studies of whether or not we included all the variables that we could control for. We tried to do that in our study."
The study found a 40% increased risk of death among the uninsured. As expected, death rates were also higher for males (37%), current or former smokers (102% and 42%), people who said that their health was fair or poor (126%), and those that examining physicians said were in fair or poor health (222%).
"This is actually a life and death struggle," said another study author, Steffie Woolhandler, MD, MPH. She noted that the current healthcare reform bills under discussion in Congress still leave millions without coverage.
"When we talk about leaving 20 or 30 million Americans with no health coverage, we're saying we as a nation—or whoever is proposing [reform legislation] is saying—it's really acceptable for 20,000 or 30,000 people to die each year from the lack of health insurance."
"That's actually more people than die from homicide in this country, more people who die from drunk driving in this country," said Woolhandler, who is a staff physician and associate professor of medicine at Harvard Medical School. "I think it's completely unacceptable for congressmen and senators to accept that many uninsured people."
Wilper and Woolhandler are co-founders of Physicians for a National Health Program, which calls for single payer national health insurance. They have produced other notable studies which have shown that 31% of health spending is for administrative costs, and 62% of all bankruptcies are linked to medical expenses.
Wilper says their advocacy for single payer doesn't undermine their study's findings. "This is a peer review journal article. This is a finding that is consistent with the bulk and mass majority of published studies in the United States," he says. "Ad hominem attacks on the study's findings won't carry much weight."
"I'm hoping it will shake up the debate in Washington," said Woolhandler.
Editor's Note: John Commins contributed to this article.
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Nearly nine-of-10 human resources and benefits executives at several hundred midsized and larger companies say their bottom line won't absorb any additional costs that may result from healthcare reform, according to a new survey.
The poll of 433 executives, conducted by Stamford, CT-based financial and risk managers Towers Perrin, found that employers are prepared to reduce benefits, raise prices for customers, and even reduce their workforces if the healthcare reforms that emerge from Congress increase the cost of providing employee coverage.
"With employer healthcare costs rising more than 150% over the last decade, it's no surprise that 90% of employers list cost containment as the most important healthcare reform goal," says Dave Guilmette, managing director of the Towers Perrin Health and Welfare practice. "Many large employers, however, feel that current reform proposals are focused on other healthcare issues—such as expanding coverage and reforming certain insurance practices—and they feel they have already addressed these issues within their own workforces.
"The way employers would respond to reform proposals that raise or lower their costs is one of our most telling findings—one that could conceivably impact economic recovery," Guilmette says. "With companies struggling to manage rapidly escalating healthcare costs and reclaim profits, only 11% of companies would agree to absorb increased healthcare costs by reducing their profits. The overwhelming majority of companies would respond to higher costs by reducing the benefits their employees receive."
The survey also found that 80% of the companies were closely monitoring the healthcare debate in Congress, 23% of them are rethinking benefit changes in light of possible reforms, and nearly 90% plan to reexamine their health benefit strategies for active employees in response to the passage of healthcare reform legislation. And while talent management considerations, such as productivity, workforce health, and recruiting and retention, remain important even in a tough economy, cost issues will dominate employers' decision making in a post-reform world, the survey found.
Employers say they are skeptical that the reforms now under consideration will address fundamental drivers of healthcare costs. For example, 65% of employers believe the reforms will have little or no impact on unhealthy consumer behaviors that promote obesity and other chronic health issues.
However, 53% of employers believe that research on comparative effectiveness will have a positive impact on their business, and 44% believe that it will be good for business to reform the health insurance market to ensure guaranteed access to coverage regardless of health status. Nearly half of survey respondents believe that an employer "pay or play" mandate would negatively impact business.
Despite the sharp focus on costs, the survey respondents expressed strong positive views on the importance of workforce health to business success, the role of health benefits in the rewards portfolio, and the opportunities benefit programs provide in influencing workforce health. Notably, 61% say they would stand by their commitments to employee wellness and health promotion programs even if they no longer offered medical benefits.
"For many companies and in certain industries, health benefits are viewed as critical to the total rewards package," says Ron Fontanetta, Towers Perrin principal. "These programs provide important levers in managing talent and supporting other key business objectives."
As for a pay-of-play mandate:
37% of employers say they would provide company-sponsored health coverage that substantially exceeds the standard.
29% of employers would discontinue company-sponsored health coverage and pay the assessment if the per-employee costs of payments to the federal government were substantially lower than their current costs.
26% would provide company-sponsored health coverage at the level of the minimum standard required.
"In some industries, particularly those with low margins and lower-income/high-turnover employee populations, some companies would, under a mandate, choose to write a check to the government and allow employees to purchase coverage in a reformed market for individual health insurance," noted Fontanetta. "For example, fully 42% of retail companies in the survey said they would close their plans and pay a federal assessment, versus 28% of those in financial services and 24% of those in technology/telecommunications."
I spoke recently with Arthur "Bud" McDowell, MD, vice president of Clinical Affairs for Middlesex Hospital in Middletown, CT. We discussed physician alignment strategies in the face of probable healthcare reform, as well as the changes his hospital has made to more closely align cost and quality.
At this point, thanks to a three-year demonstration project and a plethora of available information available for providers, the healthcare industry generally knows what providers are up against in terms of RAC audits. Not that they'll be easy to handle, but there's a lot of information out there for providers to help them manage the process.
Unfortunately, comparatively few providers seem to know what to expect with Medicaid Integrity Program audits—which have already begun in many areas across the nation—and in many cases, information that could help them is lacking.
CMS plans to update its Web site with much more information, according to CMS representatives who spoke on the last Open Door Forum call on the subject, and providers are waiting with baited breath. Providers may also be able to find some helpful information on their individual state's Medicaid Inspector General Web site. But in comparison to RACs, information on Medicaid Integrity Program audits is generally difficult to come by.
In addition, there also seems to be a lack of information available from providers who have already been audited by Medicaid Integrity Contractors (MIC). Perhaps with one more auditor to deal with, providers are simply too busy to share. But many providers are looking to their peers to reveal the lessons they learned and the strategies they developed to deal with the Medicaid auditing activities even a little more easily.
One provider recently noted that a MIC had already requested hundreds of records from her hospital—there is no record request limit unlike the one in place for RACs. They can ask for as many as they want, as often as they want, she said. "And I think we had 15 days to respond. It's ridiculous." (MICs must adhere to state laws in this regard, so the time providers have to turn in records will differ depending on the state in which they are located.)
What are MICs looking for? Again, this differs from state to state. One provider indicated evaluation and management (E/M) codes were audited in her hospital's clinic areas. "When MICs found a preponderance of higher codes that didn't exactly meet the bell curve, they asked for the documentation for the higher levels. And we had to produce it all."
RACs may also audit E/M codes, but they have chosen to begin with more straightforward, automatic reviews. In addition, at least for Medicare Part B physician claims, CMS has indicated it will work closely with the AMA and the physician community prior to any E/M level auditing and will provide notice to the physician community before the RACs begin E/M audits.
Providers need to figure out how to meet MIC record requests and appeal deadlines. And surely they'd appreciate learning about MIC target areas. But again, information is difficult to come by, and much of it will differ from state to state, making the process that much more complex.
But as one provider said: "MICs are aggressive here. Very, very aggressive. And we're really being pushed."
So providers need to learn all they can, however they can, and as soon as they can about Medicaid Integrity Program audits to help them prepare.
Editor's note: For more on Medicaid audit activities, consider attending the upcoming to the upcoming HCPro audio conference, "Medicaid Integrity Contractor Audits: Know What to Expect and How to Prepare," to be held October 15. Speakers include James G. Sheehan, the New York State Medicaid Inspector General, and Sarah Kay Wheeler, partner at King & Spaulding in Atlanta.
Keeping the many new patient safety topics and initiatives fresh in the minds of frontline caregivers can be a challenge. To make sure staff members were thinking about a new aspect of safe patient care each month and educate both them and patients together about patient safety goals, Abington (PA) Memorial Hospital (AMH) started "Patient Safety First."
The initiative is a hospital-wide patient safety campaign that focused on behaviors and actions. Originally launched in 2008, staff members decided to continue and build on Patient Safety First after seeing success in its first year.
"It was a program to help us focus, inform, and partner with our employees and patients to get the patient safety message out," says Robert C. Giannini, NHA, safety/ quality specialist at AMH's Center for Patient Safety & Quality. "It's really letting staff and our patients be on the same page for the month."
In 2009, AMH has created communication strategies for internal staff use as well as some specific for patients. At the end of 2008, staff members planned out a full calendar year of topics for each month in 2009. That helped show staff members that this program is a part of the organization's underlying mission, says Giannini.
"We do change our goals based on our priorities for that year," says Giannini. "People are seeing that this isn't going away and it's part of our culture."
To really hit home the idea of changing behaviors to improve patient safety, Giannini and his staff members designed the campaign to be apparent in the everyday working environment. Depending on the theme of the month, the topic receives attention on screensavers, in the "nursing notes" internal newsletter, in educational pieces that are posted, and via patient safety coaches, who spread the theme to fellow caregivers.
The patient safety coaches meet each month to discuss new hospital initiatives. Patient safety coaches at AMH are frontline caregivers, who are unit based and will share a specific message with their colleagues.
"We do have safety coaches in each area of the hospital, and [the monthly Patient Safety First topic] would be part of the theme of the meeting that month," says Linda Mimm, RN, BC, DL, CPHQ, safety/quality specialist at AMH's Center for Patient Safety & Quality. "It's not just a piece of paper that goes out, it's a clear team effort getting the message out also."
Additionally, Giannini and his staff members ensure that hospital staff understand where each month's theme fits in with The Joint Commission's National Patient Safety Goals as well as the organization's annual goals, he says.
Equally important to the success of this initiative has been the nursing department's ability to partner and plan with the finance department, says Elizabeth Medina, RN, BSN, CCRN, nurse manager for the cardiac surgery unit and cardiac intensive care unit at AMH. After all, nurses are a part of the frontline caregiving team that this initiative targets.
"We have a good support structure within the nursing department because we partner with finance," says Medina. "What gives us the capability to partner with things like this is we structure into our own unit budgets for the fiscal year training and orientation hours.
Patient education
Staff members in the quality/safety department develop patient education materials to alert patients to each monthly theme. For example, in January, patients received documents telling them that handwashing was a focus that month and asked them to be a partner in their own safe care. Other monthly themes have been medication safety, patient identification, increased communication among caregivers, and timely reporting of critical tests/results. In October, the hospital will focus on immunization.
Staff nurses introduce the monthly piece of education while they go over other important information about patients' stays.
"As we educate the patient, with all of the other education related to their admitting diagnosis, we also go over that piece of information as well," says Medina.
Overall, the initiative has helped the hospital as a whole incorporate many aspects of patient safety into patient care, and also hone in on specific topics. AMH has seen an increase in both staff and patient reports of concerns, suggestions, and patient safety events.
"Working in the safety/quality department, it really helps us focus as an organization on a theme," says Mimm.
Fewer physician specialties are facing critical shortages than in past years, but Massachusetts primary care physicians are still in short supply, according to a new survey of the state's doctors.
For the fourth year in a row, the primary care specialties of internal medicine and family medicine experienced shortages in 2009, said the report by the Massachusetts Medical Society. The survey questioned doctors, hospital administrators, and medical education leaders about the medical workforce.
