Nearly 73% of all Twitter users joined the micro-blogging site in the first half of this year, according to Sysomos' survey "An In-Depth Look Inside the Twitter World." About half of all Twitter users (53%) are women, and the majority are young. Among users who disclose their age, 66% are under 25, and another 15% are ages 25 to 29.
Pharmaceutical giant Pfizer is among the many healthcare marketers who are struggling with the new world of Twitter and social media. This video features Pfizer Vice President Ray Kerins as he explains the lack of federal regulations on social media for healthcare companies to a conference audience.
Does the Medical Practice Act, which bars California hospitals from hiring doctors, violate the 14th Amendment, the one that guarantees equal protection under the law?
Welcome to the latest argument in the campaign by California's hospitals to recruit and retain primary care providers and specialists by hiring them and offering them benefits.
Just like county hospitals and academic medical centers, as well as hospitals in nearly all other states get to do.
Pamela Ott, executive director of the 49-bed Sierra Kings District Hospital in the farm community of Reedley, 25 miles southeast of Fresno, thinks the law most certainly does violate the constitution. She's having trouble recruiting another obstetrician, really needs a general surgeon, and is looking for a cardiologist to set up practice in her underserved area.
Alexzandra Hollingworth, MD, a young, board certified general surgeon fears she may not be able to continue her practice in the San Joaquin Valley because "the payer mix does not provide enough money to make a living as a doctor.
"I'm not talking about a decent living," said Hollingworth, 38. "I'm talking about any living at all. I'm talking about being able to pay the rent." She also wants to work in a setting with benefits, like health insurance, as many of her friends in Virginia and New York enjoy.
Tom Petersen, a director with the Association of California Healthcare Districts, also says California's Medical Practice Act is unconstitutional. The Sacramento-based group is pushing for passage of legislation that would lift the prohibition for hospitals operating in rural areas as well as hospitals operated by special health districts as long as they serve a medically underserved population.
"The majority of the people who are harmed because of this existing law are people who are black, brown or poor, or two of those three," says Petersen. This is about people who have no one to advocate for their healthcare, and that means they're treated unequally under the law."
Other organizations and state agencies that support change include the California Hospital Association, the Medical Board of California, the Regional Council of Rural Counties, the California Alliance of Retired Americans, and many other groups.
Even Dolores Huerta, cofounder of the National Farm Workers Association with Cesar Chávez, has joined the campaign, saying she knows the scarcity of physicians in rural and impoverished parts of the state disproportionately harms patients because doctors aren't always there in emergencies, and because they have to travel much farther to get the care they need.
Unfortunately for their cause, the influential California Medical Association, which represents a large share of the state's physicians, vehemently disagrees and has defeated two of three bills that would have lifted the ban.
The remaining bill, SB 726, was heavily amended to include some of the provisions in the defeated bills.
However, as amended, the bill allows only two physicians instead of 10 to be hired per hospital, with another three allowed only if the hospital can show in a public hearing the need for additional hires.
Additionally, other provisions in SB 726 would limit its application only to hospitals in medically underserved areas and only those which can prove that they tried unsuccessfully for at least 12 continuous months to recruit physicians.
As it stands, it passed a key committee with a 15 to 2 vote in August. And is expected to be approved by the Assembly.
But the CMA may kill this bill too when it goes before the state Senate in coming weeks.
The CMA's chief objection is its fear that hospitals acting as employers would tell doctors what kinds of care their patients should get. They suggest that such direction might depend more on the allowances in the patients' insurance policies, even though specific language in the bills would prohibit that.
Another CMA argument is a fiscal one. In a letter Aug. 21 to the Assembly Appropriations Committee, CMA lobbyist Brett Michelin says such a bill would increase costs to the state with higher charges for Medi-Cal (Medicaid) patients.
"If SB 726 is allowed to become law and physician services are delivered in the hospital or hospital owned clinic, the hospital or district may become eligible for reimbursement for services provided by the facility," Michelin wrote. "This would increase costs to the Medi-Cal system for every enrolled patient that receives services at a hospital or district owned facility instead of at a physician office."
Michelin added that the ban on hospitals hiring doctors "has been preserved by the Legislature and the courts since the 1930s."
Currently, only teaching hospitals, prisons, and county hospitals are exempt from the state law. California is only one of a handful of states that has such a rule. And prohibitions in other states are rarely enforced.
Hospitals are allowed to offer physicians a minimum income guarantee for the first two years they come to certain underserved communities to start a practice.
But, Ott says the questions out of these doctors' mouths are: "That's great for two years. But what do I do after that if I can't get the volume to be self-sustaining? Why would I stay here if I can go to another state and know I could be gainfully employed, regardless of the patient care volumes I have in the future?"
Several hospital officials who have lobbied for bills similar to this one in Sacramento say every time legislation gets to the floor for a vote, a few days before, every legislator got a call from his or her personal physician.
"The physician tells the elected representative, 'You need to vote against this because I'm asking you to.' That's the same tactic CMA has used every time this has come up. Everyone gets a call," recalls a Southern California hospital government relations representative. "You can't beat that."
Rural and district hospitals in underserved areas argue that they have trouble filling their emergency room call panels because private practice physicians who take call are unlikely to get patients with insurance.
And that's true in Fresno County, where Pam Ott struggles to find doctors. A June report by the California Health Care Foundation found that Fresno County has significantly fewer specialists per capita than the state average, including anesthesiologists, cardiologists, emergency physicians, geriatric specialists, gastroenterologists, general practitioners, neonatologists, orthopedic surgeons, pathologists, psychiatrists, and pulmonologists.
According to that same California Health Care Foundation study, Medi-Cal is a large part of the problem, because the low reimbursement rates have prompted more physicians to decline to accept those patients.
"Over 50% of primary care doctors do not accept Medi-Cal or uninsured patients because what California pays doctors who treat these patients is among the lowest in the nation," says Sharon A Spurgeon, CEO/administrator for Coalinga Regional Medical Center, also in the San Joaquin Valley. "Doctors receive only $24 per office visit--less tan half of the actual cost of care. Doctors simply cannot afford to set up private practice in poor communities and hospitals in these communities are not allowed to hire doctors."
Petersen, who represents the healthcare districts, says the core message is this: "No one but those in disenfranchised populations are impacted by this. But who benefits from this policy? Who is protected? Are people better off by having their diabetes go untreated than by having it treated by an employed physician?"
"If that's true," Petersen asks, "why hasn't the CMA pursued legislation to take away the exemption that currently exists" for academic medical centers and county hospitals?
Health insurers know the importance of signing up so-called "young invincibles" to their health plans, but many of these sought-after individuals are not interested—either because they can't afford health insurance or they simply think they don't need coverage.
Health insurance companies understand that having these low-cost prospective members paying into the system could decrease member health insurance costs across the board.
Young adults between the ages of 19 and 29 are one of the largest segments of the U.S. population without health insurance, according to The Commonwealth Fund's Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help. A whopping 13.2 million, or 29%, of young adults lacked health insurance coverage in 2007. Many of those young adults lost coverage at or after age 19 when they graduated from high school or college. In fact, turning 19 increased the uninsured rate nearly threefold, according to the report.
Young adults might think they don't need insurance, but The Commonwealth Fund thinks otherwise. Not having insurance creates barriers to care and leaves young adults and their families exposed to hefty out-of-pocket costs, according to the report.
There are also health reasons why young adults need insurance. Fifteen percent of young adults have at least one chronic health condition, including asthma, cancer, or diabetes; young adult mothers gave birth to 2.6 million children in 2007; and injury-related visits to emergency rooms are more common among young adults than any other group (1,453 per 10,000), according to The Commonwealth Fund.
How can health insurers and policymakers change this trend? Here are two ways health insurers can do it:
Promote individual health insurance to both the young adults and their parents
Health insurers need to do a better job at promoting their offerings. This goes beyond creating a cute, fuzzy mascot to preach the importance of Acme Health Insurance. That may make young adults aware of you, but that still doesn't mean they know that they are eligible to sign up for those plans. They may view health insurance as something for their parents.
One way to promote your services to young adults and parents is knowing state dependent laws and reaching out to parents and children about individual health insurance options when the child reaches his or her late teens.
Now that you have informed them, it's time to take the next step. When the child reaches beyond the dependent age and loses coverage, the insurer should create a mechanism (phone call, e-mail, and/or traditional mail) to reach out to both the parents and young adults about their health insurance options. Many don't realize there is an individual insurance option available to them so it's up to insurers to tell them.
Not only would you benefit from gaining young adults as members, but your company could also acquire a life-long member.
Make individual health insurance more desirable
OK, you have the young adults signed up. Now, give them what they want and in the form of communication they want.
This will mean investing in technology and allowing them to work with their health insurer on their own schedule via the Web; diving into the social media world of Facebook and Twitter; and creating applications that allow individualized communications with the young adult.
Everything is moving toward individualism. Young adults will expect it from their health insurers too. That's the way to reach them.
And here are two pieces of state legislation that could improve health coverage access to young adults:
Increase the age that young adults can be considered dependents for insurance purposes
New Jersey and New Hampshire allow residents to cover their children under their health insurance up to the age of 30. Another 24 states have similar laws with less liberal age requirements. Most of them allow parents to cover their children until the age of 25.
States have created these laws because many young adults lose their parents' coverage once they graduate from college. The transition from schooling to the workforce often includes low wages and no health benefits and leaves many young adults without health insurance.
Providing a safety net by increasing the dependent health insurance age could resolve that issue.
Allow mandate-lite health plans
I wrote about mandate-lite plans in March 2008. Some states have options that allow insurers to offer health plans with few state mandates, which reduces the costs of offering those plans.
There are about 2,000 mandated healthcare benefits and providers throughout the country, and those mandates increase healthcare costs by more than 50% in some states, according to the Council for Affordable Health Insurance.
Some of these mandates include: Services like hair and limb prostheses, bone mass measurement, and care for TMJ disorders; providers like dentists, optometrists, and marriage therapists; and covered persons such as non-custodial children and adopted children.
The benefit of mandate-lite plans is that they are low-cost options for young adults who simply want preventive and catastrophic coverage. The downside is that they might not cover certain services, such as maternity care. So educating young adults about these plans is critical if your state provides mandate-lite options.
Those are a mere four ways that health insurers and policymakers can tackle the issue—short of implementing a federal individual mandate that would require all Americans to have health insurance. All four ideas could be implemented without much problem or capital.
In a time when the industry is facing fewer employer-based members and a potential public insurance option, think about how the infusion millions of uninsured young adults would benefit health insurers. These proposals could add new members who are lower cost than the general member population—especially elderly and sick members.
With bipartisan efforts to pass a healthcare bill sputtering, Democrats are increasingly looking at a politically risky, last-ditch option designed to ram their proposals through over the objections of the other party. Typically, the majority party in the Senate needs 60 votes to end debate and block a minority filibuster. But in the current debate, Democrats have only 59 members because of the death last week of Massachusetts Senator Edward M. Kennedy, and a handful of moderate Democrats might not support healthcare legislation without at least some Republicans on board. So Democratic leaders are discussing the possibility of passing a Senate bill with a simple majority, or 51 votes, under the "reconciliation rule."
Though Disease-specific care (DSC) certification surveys provide a little bit more notice for hospitals than The Joint Commission's triennials, a six-hospital system with multiple DSC programs may need to handle surveys uncomfortably close together.
For Main Line Health, a six-hospital system outside of Bryn Mawr, PA, this meant four surveys in three hospitals between February 2009 and August 2009. With the right prep work, however, four surveys in a six-month period did not mean panicking, says Mary McKay, RN, MS, CPHQ, system director of regulatory affairs and nursing quality. The system weathered a ventricular assisted device (VAD) destination therapy program, primary stroke center certification, and two knee and hip programs successfully in a matter of weeks.
The prep work is similar to The Joint Commission's triennial survey, says McKay.
"It's very similar—you do your annual Periodic Performance Review (PPR) and take your action plan from that," says McKay.
Surprises?
Surveyors, McKay found, were very interested in education during DSC surveys.
"One quote all of the surveyors used: What makes you different?" she says. "What sets you apart from the hospital down the street? That's a message we hadn't seen in print before, and it really drove the message home, to refine the program and give it a unique look."
The education component is more prescriptive in some programs than others.
"With stroke, there's a big education requirement," says McKay. "Each staff was asked, whether they were nursing or therapy or anyone else, what additional training you had in this area. And whether you're looking at stroke or knee and hip, or VAD, that education sets you apart."
Staff education also reflects on the hospital as a whole.
"From the surveyor's point of view, they also want to know that having this additional education shows leadership's commitment to the program. Education is part of the organization's goals," says McKay.
For their knee and hip certification program, the healthcare organization had developed an individual care plan for patient education.
"Folks come in with a pre-op visit, and that education follows them through their hospital stay," says McKay. "Post-discharge there's a chance to participate in further education."
The organization was able to demonstrate the content and initial education to the hip and knee patient, and document the patient's understanding, which reflected well on the program during the survey.
Patient education was one area where the stroke program received an RFI—in this case, it was not a case where the education was not being done, but simply a matter of documentation of such education.
"We use nursing pathways and we haven't gone fully electronic yet," says McKay. "Because we use pre-populated pathways, they were not specific enough for stroke education."
While the surveyor saw and believed that the facility was performing the appropriate level of education, the generic template for documenting this education will be improved.
This being said, the programs performed remarkably well during the surveys—two of the four programs came away without a single RFI, and the other two programs had only two findings a piece.
A lot of the success of these surveys came from the excellence of our staff education component.
"I have to give kudos to our nursing staff educators," says McKay. "I think the challenge will be in sustaining this going forward, always remembering this population of the staff needs more than the mandatory training sessions. We need to give them refreshers in joints, VAD, stroke."
The three major nurses' organizations in the country have come together to form the largest registered nurses union and professional association in U.S. history: National Nurses United. Members of the California Nurses Association/National Nurses Organizing Committee, United American Nurses, and Massachusetts Nurses Association make up the 150,000 member national organization.
After meeting last month in Minneapolis, the leaders of the National Nurses United announced that they will be holding a convention December 7–8 in Scottsdale, AZ. From now until December, each organization will have its own national convention to approve the pending union with the purpose of creating a stronger national movement of direct-care RNs.
National Nurse United also plans to put emphasis on the protection and expansion of patient rights and RN professional practice. To accomplish such goals, National Nurse United hopes to promote Senate bill, S. 1031, the National Nursing Shortage Reform and Patient Advocacy Act. The new merge will also focus to strengthen nurses' voice in the national healthcare debate.
Jeanette Parent, RN, nursing education coordinator at Dickinson County Healthcare System, has mixed feelings about this new nurses' union.
"I whole heartedly support nursing organizations that promote professionalism, leadership, and education," says Parent. However, she is concerned about super union's focus.
"The focus becomes more political with the emphasis more on how the organizations that we work in function or are governed versus the hands-on day-to-day patient care," says Parent.
Parent also fears for the nursing profession, hoping that it does not get lost in this merge.
"We are professionals and our voices strong, but there are times I do not agree with the views of one organization. If they become one, who will we get differing opinions from?"
The usual short term measures to address rising healthcare costs, such as reducing prices, will not be sufficient to "bend" downward long-term healthcare spending. Instead, President Obama and Congress should use more aggressive reforms that will slow spending growth—while improving quality, a group of 10 national health policy experts is recommending.
The group's effort was convened by the Engelberg Center for Health Care Reform at Brookings, with support from the Robert Wood Johnson Foundation. In their plan, called "Bending the Curve: Effective Steps to Address Long Term Health Care Spending Growth," they call for transitioning to a "system of greater accountability," which will provide greater flexibility for private and public stakeholders "to experiment with programs and measure results—to see what works best."
As a foundation for improving value, all stakeholders in the system need better information and tools to be more effective, they propose. Provider payments then should be "redirected toward rewarding" all improvements in quality and reductions in cost growth.
In addition, they call for health insurance markets to be reformed and government subsidies restructured "to create competition and improve incentives around value improvement rather than risk selection." And they suggest that individual patients be "given greater support for improving their health and lowering overall health care costs."
To get there, they are calling for a series of steps to accomplish those goals:
Building a foundation for cost containment and value based care. Holding spending growth while improving value will require information and tools, such as health information technology (IT) systems, they said. However, providing these tools is not enough—stakeholders will also need better incentives to use them.
Efforts should be made to ensure that investments in health IT are effective by linking "meaningful use" health IT bonuses to achieve better results; creating interoperability and provider communication; and funding technical support programs to ensure providers adopting health IT have access to comprehensive support for overcoming implementation challenges.
The best use of comparative effectiveness research (CER) should be sought by creating an entity to allocate CER funding based on the expected value of the evidence to be developed, while protecting providers and insurers from liability when they follow best practices identified by evidence.
The healthcare workforce should be improved through creating incentives for states to amend the scope of practice laws to allow for greater use of nurse practitioners, pharmacists, physician assistants, and community health workers. Also, graduate medical education payments should be amended to promote the teaching of high value care practices.
Reforming provider payment systems to create accountability for lower cost, high quality care. Reorienting providers' financial incentives and support toward improving value is essential and requires both a short and long term strategy, the experts noted.
Initially, they call for adjusting the Medicare and Medicaid fee-for-service program, which could include broadening bundled payments (such as hospital and post acute care, hospital and physician services, and high cost episodes of care) and increasing payment rates for primary care—offset by reductions for specialty care.
New payment systems should be built for provider accountability. Pilot accountable care organizations (ACOs) should be promoted that integrate physician groups, hospitals, and other providers around the ability to receive shared savings bonuses by achieving measured quality targets.
Pressure should be applied to "non accountable" Medicare payments by, for instance, establishing virtual ACO incentives several years after implementing reforms and by freezing marketbasket updates for two years for providers not participating in accountable payment systems.
Improving health insurance markets. "Governments should ensure proper incentives for non group and small group health insurance markets to focus on competition based on cost and quality rather than selection," they said. Achieving this will require near universal coverage and insurance exchanges, they added. Also, lawmakers should reform Medicare Advantage to improve incentives for lowering costs.
Non group and small group markets should be restructured around an exchange model that promotes competition on cost reduction and quality improvement.
Inefficient subsidies for employer-provided health insurance should be reduced, such as through capping existing income tax exclusion for employer provided insurance.
Supporting better individual choices. Individuals need support for "making better choices as patients and consumers," they said, that would enable them to get better care and stay healthier at a lower cost.
Medicare should be redesigned to "reward high value choices and discourage first dollar coverage."
Prevention and wellness programs should be promoted that reduce costs, such as by targeting obesity reduction and allowing premium rebates for measurable health and risk factor improvements, provided that all beneficiaries have an opportunity to save money.
Patient preferences should be supported for palliative care.
The healthcare policy experts who joined together to develop the proposal include: Joseph Antos, PhD, American Enterprise Institute for Public Policy Research; John Bertko, The Brookings Institution; Michael Chernew, PhD, Harvard Medical School; David Cutler, PhD, Harvard University; Dana Goldman, PhD, University of Southern California and RAND Corporation; Mark McClellan, MD, PhD, Engelberg Center for Health Care Reform at the Brookings Institution; Elizabeth McGlynn, PhD, RAND Corporation; Mark Pauly, PhD, University of Pennsylvania; Leonard Schaeffer, University of Southern California; and Stephen Shortell, PhD, University of California, Berkeley.
Despite recent obstacles, conservative Democrats indicate that many of the lawmakers still believe approval of some form of healthcare plan is achievable and far preferable to not acting at all. Obama administration officials said they found that most Democrats remained engaged and eager to explore ways to reach agreement. "For the lion's share of Democratic members of Congress, this isn't about looking for a way to make this disappear," said Rahm Emanuel, the White House chief of staff, about the healthcare issue. "This is about trying to find common ground for a yes vote."
Lawrenceville, GA-based Gwinnett Medical Center's bid to perform open-heart surgery has set up a fight with Emory and Piedmont hospitals, which already perform the procedures. The conflict centers on Gwinnett's arguments for access to care vs. the other hospitals' assertion that another heart center will flood the market, driving up costs and driving down the quality of care. Both sides maintain their position represents the best interests of healthcare for the Atlanta area.
