The development of enough safe and effective vaccine is key to preparations for combating the expected proliferation of the H1N1 virus. Around the world, the health industry is busy producing and testing it while officials try to prepare the nation's hospitals, clinics, and public health agencies. But it is unknown how quickly sufficient vaccine can be produced and whether millions of people may be delayed in getting it because of nagging production complications.
As part of the stimulus package, the U.S. government is temporarily reducing healthcare premiums by 65% for some people continuing group health coverage under the Consolidated Omnibus Budget Reconciliation Act, or Cobra. Individuals have 60 days from the time they're notified of their eligibility to accept Cobra. The Cobra subsidy can lower an individual's monthly premium to about $140 from about $400, according to the Kaiser Family Foundation.
When it comes to protecting Medicare dollars, they share the responsibility of ensuring healthcare providers are paid correctly for services provided, and both conduct audits to help ensure as much.
But once a MAC audits a service, a RAC cannot. And vice versa. So, does that mean there might be a little friendly competition between them?
Deborah K. Hale, CCS, president and CEO of Administrative Consultant Service, LLC, who spoke during the August 13 audio conference, "Inpatient vs. Observation Service: Level of Care Compliance in a Challenging Regulatory Environment," said she's seeing a little bit of competition between MACs and RACs across the country. "We'll have to see how this pans out," she said. "But since those agencies do have the same responsibility, we may see more activity from the MACs than we do from the RACs."
TrailBlazer, a MAC for Hale's home state of Oklahoma, conducted an audit of 250 inpatient discharges for MS-DRG 247 (the DRG for coronary artery drug-eluting stent without a secondary diagnosis that counts as a major complication/comorbidity), according to a TrailBlazer Job Aid.
There was a 98.8% level of care error rate, according to the audit, meaning TrailBlazer recouped reimbursement in 98% of cases. "For most hospitals, that amount is in the $12,000 range," Hale said. "That's a pretty nice slice of reimbursement, and that leaves the hospital having to donate that drug-eluting stent at no charge."
(The MAC denied 87% of the cases because it believed the provider should have performed the procedure in an outpatient, rather than inpatient setting. Another 11% were denied because providers didn't submit requested medical records.)
And that's not all. During a recent HCPro focus group call, one healthcare provider recently reported seeing a 70% increase in audit activity by commercial payers at their facility.
Health and Human Services (HHS) Secretary Kathleen Sebelius traveled to Maine this week to release a new report on health insurance reforms related to older women (ages 55 to 64) and senior women (ages 65 and older). The report's message—which gave another nudge to Obama administration's healthcare reform efforts: The current health insurance market "does not work for older women."
"Our mothers and grandmothers have unique health needs and under the status quo—they aren't getting the quality, affordable care they deserve," said Sebelius, who participated Thursday in a roundtable discussion in South Portland that sponsored by AARP and the Maine Women's Lobby.
Overall, women appeared to be more susceptible to incurring high medical costs--even when they have health insurance, the report stated. A recent study found that nearly half of all women reported problems paying medical bills—compared with 36% of men, and a third of women were faced with making a "difficult tradeoff" between using up their savings, taking on debt, or giving up basic necessities.
The issue of high out of pocket costs was particularly prevalent among older women, who were more likely to be lower income than men of the same age (28% versus 23%). Also, 42% of older women had two or more chronic conditions--compared with only 32% of older men—which adds to healthcare costs.
Overall, older women were more likely to incur greater out-of-pocket costs. More than 5% of older women lived in households with high out of pocket costs, compared with 4% of older males. For older women living alone, 8% had high out of pocket costs compared with 5.5% for men.
Among other healthcare problems impacting women are:
Prevention is underemphasized. Measures that can go a long way to help make sure cancer is caught early, such as preventive screenings, are not being used often enough by older women. One in five women aged 50 and above has not received a mammogram in the past two years, and 38% of adults aged 50 and over have never received a colorectal cancer screening.
Access to care is difficult in rural and underserved areas. Approximately 12 million seniors, of which 56% are women, lack access to a primary care provider because of shortages in their communities.
Prescription drug price costs are high. Rising drug costs also contributed to the high out of-pocket costs for senior women—even after drug benefits were added to Medicare in 2006. In 2007, more than 8 million seniors hit the gap in coverage known as the "doughnut hole"—64% of those seniors were women.
Long term care coverage is inadequate for senior women. About 77% of Medicare beneficiaries living in long term care facilities are women, and most of the difference in out of-pocket costs between senior men and women are a result of long term care costs.
The nation's hospitals shed 700 jobs in August, posting the second such month-to-month decline since June, when overall hospital payrolls shrank by 200 jobs, according to the Bureau of Labor Statistics' seasonably adjusted preliminary data.
Even with the slight decline in August hospital employment—which is based on preliminary data and subject to considerable revision in the weeks ahead—the healthcare sector continues to be one of the few job growth areas in the sluggish economy in 2009, BLS figures show.
Overall, the healthcare sector—from physicians' offices, to residential mental health homes, kidney dialysis centers, and blood and organ banks—reported 27,900 payroll additions in August, and 180,400 new jobs in the first eight months of 2009, according to BLS' preliminary data. In the first eight months of 2008, the healthcare sector grew 242,100 new jobs, and averaged 30,262 new jobs per month, preliminary data show.
Nearly two-thirds of job growth in the healthcare sector is in ambulatory healthcare services, which reported 18,300 new jobs in August and 119,600 new jobs in the first eight of 2009, BLS preliminary data show.
For hospitals, however, the preliminary August figures show a sharp reversal from the 2,600 new hospital jobs reported preliminarily in July. Hospital payroll growth is well off the pace set in recent years, when the hospital sector added 13,900 jobs in August 2008, and 8,300 jobs in August 2007, BLS data show.
In the first eight months of 2009, the nation's hospitals reported 17,100 payroll additions, preliminary data show, compared with 94,100 payroll additions in the first eight months of 2008, and 66,800 additions for the same period in 2007. BLS reports that there were more than 4.7 million hospital payroll jobs at the end of August 2009.
If hospital payroll increases continue at this pace, fewer than 25,650 new jobs will be created in 2009, as compared with 137,100 new hospital jobs in 2008; 105,700 new jobs in 2007; and 81,400 new jobs in 2006, BLS data show.
Even with the slowing payroll additions, the healthcare sector is still outperforming the overall economy. BLS preliminary data show that the nation shed 216,000 jobs, and that nonfarm unemployment rose to 9.7%, in August, compared with 9.4% in July. Since the start of the recession in December 2007, 7.4 million people have lost their jobs, and the unemployment rate has increased by 4.8%.
Since December 2007, the healthcare sector has created 574,500 new jobs. BLS preliminary data show that there were more than 13.6 million healthcare sector jobs in August. Also in that time, hospitals created 166,400 new jobs.
The figures released today are preliminary and subject to significant revision. In June, for example, preliminary BLS preliminary data showed 3,700 new hospital jobs created nationwide. As the data was refined, however, BLS revised its figures and now reports that hospitals cut 200 jobs for the month.
Seasonally adjusted data, which are used in this story, allow for better month-to-month comparisons that better reflect changes in economy, rather than seasonal employment patterns. Payroll growth also reflects the number of new jobs, not the number of new employees, because one person can have more than one job.
I've been reading a lot about Russian history lately—especially the history that led to the overthrow of the last czar, Nicholas II, and the events of the so-called October Revolution that threw the largest country in the world into chaos. The revolution led to the murder of the czar and every member of his immediate family—and that's just for starters.
What does Russian history have to do with leadership in healthcare? Good question. Not much, really, on the surface, but if you're looking for perhaps the best example of how not to lead people, the last czar is the mother lode.
Leadership means many different things to people. To some, it means courage in the face of adversity—the ability to spur on those who are led to great acts of bravery. To others, it might mean developing a vision for the organization they lead, and the ability to inspire others to help in achieving that vision.
But perhaps leadership can't easily be captured in such grandiose situations as I've presented so far. Leadership, to me, is most often an accumulation of small acts that inspire those who are led. I came across an example of such a small act earlier this week, while reading a study about executive compensation trends at nonprofit hospitals.
Hospitals haven't been exempted from the worst recession since the Great Depression. We've run countless stories on hospitals laying off employees, cutting back on capital plans, and generally paring expenses. Showing leadership in such tough times mostly isn't about how much you cut back, but how you do it.
Here's what I mean. According to Yaffe & Co.'s most recent executive compensation report on nonprofit hospitals, some 59% of hospitals that responded to their survey indicated that they planned to freeze salaries in their organizations. However, 35% of hospitals planned only to freeze salaries of the CEO and other top executives in the organization, and 6% were freezing the salary of the CEO only. Freezing salaries across the organization is one thing, but allowing lower-level folks to continue to have increases while the CEO and other top executives experience a freeze in their pay takes true leadership.
Let's be honest. A salary freeze for the CEO and other top executives isn't a huge sacrifice for most of these people. It's not as though they're going to miss a car or house payment or have less food to put on the table. But a salary freeze for the lower-level folks might mean just that. Further, sacrificing while your underlings aren't asked to do the same is a powerful tool that more CEOs might be interested in further investigating.
For a relatively small cost, the people you lead just might be a little bit less self-interested, and a better organization could be the result.
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A public insurance option as part of the healthcare reform measure has a number of friends on Capitol Hill—mainly Democrat. And the public option has number of foes as well—mostly Republicans.
But recently, one Republican senator's idea has re-emerged regarding a public option that she thinks might encourage opponents to change their minds—at least within the moderate ranks.
Sen. Olympia Snowe (R-ME) is one of the three Republican members on the six-members Senate Finance Committee panel that has been hammering out a health reform proposal during the summer congressional recess. It is known that the panel is looking at ideas besides the public option—such as state cooperatives—but are other ideas viable as well?
Snowe is pushing for a "trigger plan," which would feature nonprofit agencies offering health insurance only in instances in which private insurers could not cover 95% of the people in their regions with plans costing no more than about 15% of the individual's or household's annual income. She has explained earlier that her option could be made available in states from "day one in any state" where "affordable, competitive plans" currently do not exist.
Such a proposal might draw support from those Democrats—such as Sen. Tom Carper from Delaware or Ben Nelson from Nebraska—who are not satisfied going in the direction of a full-fledged public option as proposed in the Senate Health, Education, Labor and Pension bill.
However, some of the Democrats solidly behind the public option—such as Sen. Charles Schumer (D-NY) or Sen. John Rockefeller (D-WV)—may not support what they might view as a watered-down version of the option.
On the other side of the Hill, the Congressional Progressive Caucus, which is made up of 83 liberal lawmakers, sent President Obama a letter Thursday saying a health bill "without a robust public option" would not achieve the health reform "this country so desperately needs." They said they would not "vote for anything less."
So, which way will Congress turn? In recent weeks, interpretations have been bouncing back and forth on whether President Obama would consider signing health reform legislation with or without a public insurance option. Snowe's proposal could ensure that the option remains—but on terms that might be more compatible to lawmakers uneasy over full-fledged competition with health insurers.
The 12 California hospitals receiving the latest fines for putting patients in "immediate jeopardy" of harm or death include three that failed to remove sponges or towels from surgical patients, one where a psych tech repeatedly slapped an unconscious patient in the face in the belief he was "faking it," and another where staff failed to properly use restraints, resulting in a patient's critical fall.
Poor training of medication use resulted in a heparin overdose that caused a brain hemorrhage in a patient at a sixth facility while at a seventh hospital, managers failed to properly staff the intensive care unit, and a patient whose condition was quickly deteriorating was not adequately treated.
The penalties of $25,000 per hospital have been levied 98 times to 67 acute care facilities under a law that took effect in 2007. Only one other state, Minnesota, has a similar enforcement regulation, said Kathleen Billingsley, deputy director of the Center for Health Care Quality, California Department of Public Health.
Some have been levied fines as many as three times, and some for repeating similar violations.
"It is imperative that hospitals promptly respond to the issues identified by the Department of Public Health and I am pleased to say that the hospitals have done so," she said in a news conference Thursday. "Our goal . . . is to improve the quality of healthcare in all California hospitals."
However, Billingsley acknowledged that not all hospitals are accepting the fines. Of the 87 filed prior to this announcement, 63 have been paid, but 24 remain in appeal or settlement discussion. The state has been paid $1.8 million so far, an amount that includes fines for medical records breaches, such as those in the Octo-Mom disclosure at Kaiser Permanente in Bellflower.
The funds are to be used for special quality improvement projects, and suggestions from hospitals on how to use the money in specific demonstration projects are being solicited, Billingsley said.
"Under state law, hospitals are required to report to state officials any incident involving 28 "never" events, which include patient death or serious disability associated with a medication error, death or significant injury of a patient or staff member resulting from a physical assault, unintended retention of a foreign object in a patient after surgery or other procedure, patient death or serious disability associated with a fall or associated with the use of restraints or bedrails."
Last year, Governor Arnold Schwarzenegger signed legislation to significantly increase the fine for administrative penalties for violations or deficiencies constituting an immediate jeopardy to the health and safety of patients. The new law, which took effect Jan. 1, 2009, increases fines from $25,000 to $50,000 for the first violation. Incidents in this news release occurred in 2007 and 2008, before the new law took effect.
The following hospitals had these immediate jeopardy incidents:
1. At Southwest Healthcare Systems, Riverside, in Riverside County, hospital managers reportedly failed to have the minimum number of two adequately trained staff in intensive care unit beds, which had been converted from medical surgical/telemetry beds without approval. That resulted in inadequate care for at least one patient. An RN nurse told investigators, "It would be nice to have two nurses. Sometimes I have to stand by the door and yell out to get somebody to help me," noted the California Department of Public Health.
Also, since the bed had previously been used for medical surgical and telemetry, the medication and supplies were not allegedly sufficient for caring for a patient in ICU. The hospital, previously named Universal Health Services of Rancho Springs, has been fined twice before for failure to provide adequate on-call physician coverage and for failure to ensure proper food controls, according to the California Department of Public Health.
2. At Arrowhead Regional Medical Center, Colton, in San Bernardino County, a psych tech repeatedly slapped a patient in the face. The patient, who had self-inflicted cuts and was said to be a danger to himself, had passed out, but the psych tech told other techs and a charge nurse in the room, "he's faking it." Also, another psych tech who witnessed the incident said he didn't like what was happening, but "didn't feel comfortable approaching him (the first psych tech) because the few times I did he would just curse at me. The charge nurse was not going to talk to him either because he would do the same to her," reported the California Department of Public Health.
3. At Enloe Medical Center, Esplanade, in Butte County, an 82-year-old woman suffered an intracranial hemorrhage and left-side paralysis after a reported overdose of heparin by a staff person who lacked training in medication administration. Also, "the facility failed to identify the loss of the pharmacy's software system's ability to automatically access critical drug related laboratory values following a software update. The cumulative effects of these systemic problems resulted in the pharmacy's inability to provide pharmaceutical services and care in a safe and effective manner resulting in serious injury to patient 1 and posed a significant risk for injury or death to other patients," noted the California Department of Public Health.
This is the third penalty for Enloe, which was fined in 2007 and 2008 for failure to implement policies and procedures for safe and effective administration of medications, according to the California Department of Public Health.
4. At Mark Twain St. Joseph Hospital, San Andreas, in Calaveras County, improper use of restraints resulted in a fragile patient's fall with a fracture to the femur. The patient was then placed "on comfort care," noted the California Department of Public Health.
5. At Children's Hospital, Orange, in Orange County, a child with a ventriculostomy fluid drain was improperly managed, resulting in serious brain injury to the child, according to the California Department of Public Health.
6. At Kaiser Foundation Hospital and Rehabilitation Center, Vallejo, in Solano County, a surgical patient who was discharged had to return to the operating room for a second surgery three weeks later after her pain was attributed to a retained sponge, according to the California Department of Public Health.
7. At Los Angeles County University of Southern California, Los Angeles, in Los Angeles County, surgeons treating a patient with a gunshot wound reportedly forgot to remove two lap towels and three lap sponges. Also, they allegedly failed to use a recommended x-ray to detect foreign surgical objects and instead used fluoroscopy, which failed to detect the items. This is the second fine against LA County. Another in 2008 found the hospital had failed to provide adequate nursing care to meet a patient's needs, according to the California Department of Public Health.
8. At Mercy San Juan Medical Center, Carmichael, in Sacramento County, staff reportedly failed to adequately secure a bedside rail back up on a gurney, causing a 91-year-old patient on medication that would put him at risk of a fall to fall out of bed. He fractured his left hip, which required surgery to repair, noted the California Department of Public Health.
9. At Hoag Memorial Hospital Presbyterian, Newport Beach, in Orange County, the staff failed to ensure continuous patient monitoring in a patient with heart arrythmia. "Subsequently, Patient A was found to have suffered ventricular fibrillation, coded, and expired." This is the hospital's second penalty. In 2008, it failed to remove a foreign object necessitating a second surgery, which put the patient at additional risk, noted the California Department of Public Health.
10. At St. Helena Hospital, Clearlake, Lake County, staff failed to remove all parts of a stapling instrument used in a procedure to surgically remove the lower colon. "No staff member noticed that the instrument was not complete." Several days later, "Patient 1 had a bowel movement and noticed a clanking noise in the commode. A metallic structure found in the commode was determined to be the upper part of the stapling apparatus. The structure was subsequently forwarded to the manufacturer for evaluation of a possible defect," noted the California Department of Public Health.
11. At Sutter Lakeside Hospital, Lakeport, in Lake County, staff forgot to remove a sponge in a patient who underwent abdominal surgery, "which "placed the patient at risk for infection and complications from a second surgical procedure to remove the lap sponge," noted the California Department of Public Health.
12. At South Coast Medical Center, South Laguna, in Orange County (formerly Mission Hospital Laguna Beach), staff left five sponges in a surgical wound of a patient, "requiring another major surgery and the risks of general anesthesia to remove the sponge," according to the California Department of Public Health.
When it comes to reporting a physician to the National Practitioner Data Bank (NPDB), hospitals can sometimes find themselves between a rock and a hard place. Hospitals are obligated under the Health Care Quality Improvement Act to report physicians whose privileges have been denied or revoked under certain circumstances, but in doing so, they run the risk of being sued by those same physicians.
Such is the predicament that Georgetown University Hospital is facing now. Carlos F. Gomez, MD, is suing Georgetown University Hospital for $1.25 million for rejecting his application for staff privileges and reporting Gomez to the NPDB, according to an August 28 Washington Business Journal article. Gomez, who has a history of substance abuse, but has been sober for the past five years, alleges that Georgetown rejected his application based on his scarred past.
"Hospitals generally wouldn't say that you can't have a history of substance abuse to qualify for privileges," says Sally Pelletier, CPMSM, a credentialing consultant based in Intervale, NH. "They would use much broader language to determine the applicant's ability to perform. Basically, the burden would be on the applicant to resolve any doubt that his physical and mental health would not impair his ability to perform the privileges he is requesting."
Gomez claims that Georgetown reported to the NPDB that the reason for denying him privileges was due to "diversion of controlled substances," although HealthLeaders Media cannot confirm this because neither the public nor media have access to the NPDB.
In January, Gomez and Georgetown signed a settlement agreement under which Georgetown agreed to tell Gomez's potential future employers that the reason for his denial of privileges was due to "concerns about his current clinical ability to care for patients due, in part, to his length of time away from clinical practice," according to the Washington Business Journal article.
Although this settlement agreement may have been intended to help Gomez find fruitful future employment, it does not negate the hospital's federal obligation to report to the NPDB, Pelletier explains. Thus, the question may be not whether the hospital should have reported Gomez, but whether it reported him correctly.
"Generally, hospitals don't knowingly provide false information and they take precautions, such as seeking legal counsel before reporting a physician," says Pelletier. "Sometimes the NPDB categories are not clear, so hospitals may struggle to choose the category that truly defines the reasons they denied someone privileges."
A hospital wouldn't go through the trouble of reporting a physician unless it felt it was on firm ground, adds Sandra DiVarco, an attorney with McDermott Will & Emery LLP in Chicago. "Clearly, someone thought that they were in the right making the report, but if all they were looking to do was reject his application, there were likely other ways they could have done it that would have been less burdensome for them."
Credentialing professionals often have to make a difficult choice. In some cases, they can simply not process a physician's application if the physician does not meet the hospital's privileging criteria. In such circumstances, the physician does not have the right to a fair hearing or any other means of legal retribution. However, if the credentialing professional feels that patients would be put in jeopardy if this physician was not reported to the NPDB, the hospital may choose to deny the application, which opens the door for the physician to pursue legal action.
"Some hospitals take the denial route if they truly feel that they are doing the right thing to protect patients in the future due to competency issues," says Pelletier.
In addition to NPDB reporting accuracy, this case brings up another issue: Possible lack of communication between recruitment and those performing the credentialing function. Those not familiar with the intricacies of the credentialing function may not realize that there are defined qualifications and standards that must be met prior to the granting of membership or clinical privileges.
Gomez, a palliative care physician who serves as the medical director of the D.C. Pediatric Palliative Care Collaboration, was recruited by Georgetown's palliative care faculty. Those faculty members allegedly knew about Gomez's past substance abuse problem, but may not have alerted the credentialing committee (which subsequently denied Gomez privileges) of the recruitment.
"Sometimes, by the time the application gets to the credentialing specialist, they are finding all kinds of problems that should have and could have been identified during the recruitment process," says William K. Cors, MD, MMM, CMSL, vice president of medical staff services at The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.
Clear communication could have potentially avoided the NPDB report by thwarting the recruiting process and preventing the denial of privileges in the first place.
Protecting healthcare workers against transmission of H1N1 is a primary concern in healthcare settings, but existing evidence suggests that medical masks may not be effective, in part because many healthcare workers either don't use them or use those that aren't fitted properly to their faces.
Because of that concern, an Institute of Medicine committee this week issued two recommendations on protecting workers in healthcare settings against this new influenza strain.
Workers who are in close contact with individuals, who have nH1N1 influenza or influenza-like illnesses, should use fit-tested N95 respirators, which fit better than looser medical masks, to help guard against respiratory infection.
However, the committee said, scientists do not know to what extent flu viruses spread through the air or whether infection requires physical contact with contaminated fluids or surfaces or is exclusively transmitted through airborne particles.
Because of that, the committee advocates a boost in research to answer these questions and design and develop better protective equipment to enhance workers' comfort, safety, and ability to do their jobs.
"Based on what we currently know about influenza, well-fitted N95 respirators offer healthcare workers the best protection against inhalation of viral particles," said committee chair, Kenneth Shine, executive vice chancellor for health affairs at the University of Texas System, Austin, and former president of the Institute of Medicine.
"But there is a lot we still don't know about these viruses, and it would be a mistake for anyone to rely on respirators alone as some sort of magic shield. Healthcare organizations and their employees should establish and practice a number of strategies to guard against infection, such as innovative triage processes, handwashing, disinfection, gloves, vaccination, and antiviral drug use," he said.
Studies have shown that inhalation of airborne viruses is a likely route of flu infection. However, it is not clear that airborne transmission is the sole or main way the disease spreads.
N95 respirators and medical masks both cover the nose and mouth. But medical masks are worn much more loosely, while respirators are designed to form a tight seal against skin.
If properly fitted and worn correctly, N95 respirators filter out at least 95% of particles as small as .3 micrometers, which is smaller than influenza viruses.
The report was sponsored by the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration.
In a letter to the Centers for Disease Control and Prevention, Kenneth I Shine, MD, and M.E. Bonnie Rogers, chair and vice chair respectively of the Committee on Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A, wrote:
"The need for research in a number of areas was striking. Due to the lack of a strong and conclusive evidence base, the committee concluded that determination of the relative contribution of each route of influenza transmission is essential for long-term preparedness planning."
