While some experts have warned that the full disclosure approach to medical errors could lead to more lawsuits and higher payouts, the experience of the University of Illinois Medical Center at Chicago suggests otherwise. In 2004, the hospital created a consultation service to help staffers communicate quickly with patients and families about safety incidents; in 2006, that evolved into a policy of full disclosure, apology, and a swift offer of financial compensation. Over the four-year period, the number of lawsuits dropped 40% from the prior five years, and there has been no increase in financial payouts, according to chief safety officer Timothy McDonald.
In an effort to reverse the trend of people killed because of medical errors, some hospitals like Baptist Children's Hospital in Miami are taking steps to admit grievous mistakes and to learn from them in order to overhaul flawed procedures. That represents a sharp departure from hospitals' traditional response when something goes terribly wrong: Retreating behind a wall of silence to guard against potential lawsuits. Now, some hospitals are hoping to stem the tide of lawsuits by being more open with aggrieved patients and their families.
Sen. Charles Grassley signaled growing skepticism about the likelihood of Democrat-led healthcare legislation passing this year, telling a town-hall meeting, "Now is the time to do this right or not do it." The senior Republican member of the Senate Finance Committee is central to the national debate as the bipartisan leadership of that committee struggles to forge a compromise plan.
The Republican Party issued a new salvo in the health debate with a seniors' healthcare "bill of rights" that opposes any moves to trim Medicare spending or limit end-of-life care to seniors. Intended as a political shot at President Barack Obama, the Republican National Committee manifesto marks a turnaround for a party that had once fought to trim the health program for the elderly and disabled, which last year cost taxpayers more than $330 billion.
An alliance of liberal advocacy groups is stepping up pressure on Democratic senators to declare their support for a government-backed health insurance plan. The alliance hopes that by getting at least 50 senators on the record as supporting a public option, they can persuade other fence-sitters to jump to their side and push through a bill with a public option, even if only with Democratic support. So far, they say, 45 senators, all Democrats, have said "yes."
Since the Internet's earliest days, patients have used the Web to share experiences and learn about diseases and treatments. But now advocates like say that online communities have the potential to transform medical research, especially into rare diseases that lack the number of patients needed for large-scale studies and rarely attract research financing from the drug industry.
Policy experts say people are rightly concerned about the nation's healthcare costs, but they should not worry that health reform will lead to a system of medical rationing anytime soon. Those fears, the experts say, seem to stem from talk of a government-run health plan or proposals for government-sponsored research to determine which medical treatments are most effective. But few health policy experts see the likelihood of lawmakers' adopting a new system in which government bureaucrats decide whether someone's grandfather can get his hip replaced.
The FY 2010 skilled nursing facility (SNF) final rule, which the Centers for Medicare & Medicaid Services (CMS) recently released, includes components that will change some facility processes related to therapy services and ultimately affect resource utilization group (RUG) classification.
Effective October 1, 2010, CMS will:
Eliminate section T of the Minimum Data Set (MDS)
Introduce an optional start-of-therapy Other Medicare Required Assessment (OMRA)
Modify the assessment reference date (ARD) requirements for the end-of-therapy OMRA
Revise the reporting process for short-stay residents
Although the changes aim to increase the accuracy of payments to facilities, many providers are concerned about the financial pressures and increased workload these changes may cause.
Section T of the MDS is used to estimate how much therapy a resident will receive in the first 14 days of a SNF stay, which drives RUG classification. However, the Government Accountability Office found that "one-quarter of the patients classified using the estimated therapy minutes did not receive the amount of therapy they were assessed as needing," according to the final rule. CMS' decision to remove section T of the MDS will help prevent inappropriate RUG classification due to therapy projection and better align reimbursement with the actual services provided.
Some providers are concerned that the elimination of section T could mean that data would not be captured for days when therapy services were actually provided. CMS addresses these concerns by introducing an optional start-of-therapy OMRA with an ARD five to seven days from the start of therapy.
This optional OMRA would reclassify the resident into the appropriate rehab RUG and payment under this RUG would begin on the day therapy started. CMS will also require that facilities complete an end-of-therapy OMRA within one to three days after all therapy is discontinued, instead of the current requirement to complete this assessment within eight to 10 days after all therapy ends. This will prevent facilities from getting paid a higher rehab RUG for days when no rehab was provided.
In the SNF final rule, CMS also calls to revise the reporting the rehab RUG classification process for short-stay residents, which are defined as residents who are discharged on day 8 of the SNF stay or earlier. This revised process will calculate the rehab RUG for short-stay resident by using items from the MDS 3.0, including the number of therapy minutes provided, date of admission, date therapy started, ADL level, and the ARD. According to the final rule, classification into rehab RUGs for short-stay residents "will be based on the average daily minutes of therapy provided," which are as follows:
Average daily therapy minutes are between 15-29 minutes = Rehabilitation Low category (RLx).
Average daily therapy minutes are between 30-64 minutes = Rehabilitation Medium category (RMx)
Average daily therapy minutes are between 65-99 minutes = Rehabilitation High category (RHx)
Average daily therapy minutes are between 100-143 minutes = Rehabilitation Very High category (RVx)
Average daily therapy minutes are 144 or greater = Rehabilitation Ultra High category (RUx)
Even though CMS does not believe that these changes will produce financial pressures and have taken steps to ensure they do not result in an increased workload, these components of the final rule will modify many facility processes related to therapy services and SNFs should ensure their staff are well trained and prepared to adapt.
The Joint Commission has crafted a new mission/vision statement intended to more clearly explain the organization's goals and values, according to an official announcement by the accrediting organization.
The Board of Commissioners approved the new statement at its August 7, 2009 meeting.
According to its mission statement, The Joint commission strives "to continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value."
The board also approved a vision statement, stating that people should "always experience the safest, highest quality, best-value healthcare across all settings."
"I applaud the Joint Commission for the fervor evident in the new mission statement and am pleased the statement demonstrates a desire to collaborate with key stakeholders," says Marsha Barnden, MSN, RNC, director clinical processes and standards at Adventist Health. "While this is an essential component, I have to say that the most impressive change is stating the desire to inspire healthcare organizations to excel."
Being a former Joint Commission surveyor herself, Barnden says the most successful surveys are often those that the team has "worked hard to ensure the process is consultative, collegial, and educational."
"I do have some concerns, however, about a vision that includes 'all' people 'always' experiencing the safest and highest quality care across 'all' settings because it seems a lofty and unrealistic goal," says Barnden.
"On the other hand, why not reach for the stars—perfection never hurts," she adds.
Despite the positive news from a Thomson Reuters study last week, which found that hospital margins had rebounded in the first quarter of 2009, the troubles of the last 12 months may not be behind anyone just yet. Moody's Investors Service for one, doesn't hold out much hope for a strong financial performance for either the for-profit or the nonprofit hospital sectors in the coming months given that the business climate is likely to remain weak. In a report released last week from the credit rating agency, Moody's analysts say the outlook for both the for-profit and nonprofit hospital sectors is expected to remain negative over the next 12 to 18 months.
The report: "U.S. For-Profit Hospitals Face Further Uncertainty" focuses primarily on the for-profit sector. It finds that while for-profit hospital companies posted strong financial results along with improved credit metrics in the first half of 2009, there are just too many other factors going against them that will likely drive up costs, cause volumes to remain flat, and push down reimbursement from both government and commercial payers.
"The main drivers for us are the expectation that volume growth will continue to be challenging, uncompensated costs are likely to increase, and pricing growth is not likely to be sustainable at the levels we have seen in the past," says Moody's vice president and senior credit officer, Dean Diaz.
The report's conclusions are somewhat puzzling because in July, Moody's issued a report saying that uninsured volume and uncompensated care costs have been relatively flat since March 2008 for investor-owned hospitals. But analysts attributed that blip to the COBRA stimulus subsidy, as well as to an effort by hospitals to qualify more patients for financial assistance.
At any rate, recent improvements in for-profit hospitals' operating performance are not sustainable, say analysts, namely because we are at a 26-year high for unemployment. This of course will ripple across the industry, causing the number of people without insurance to rise, followed by an increase in uncompensated care costs. Further, the stimulus money, which helped subsidize COBRA, may not continue to hold down costs because it is only a temporary fix.
Diaz says volumes and uncompensated care are more broadly influenced by economic conditions, while pricing, or reimbursement, is partially driven by pressures on commercial insurers. The report says that hospitals will find it "increasingly difficult to maintain the current level of increases in managed care reimbursement over the longer term," because of a decline in commercial members and changes in insurers' Medicare Advantage business.
To that end, my colleague Les Masterson reported in early August that Fitch Ratings had revised its rating outlook of six health insurers from stable to negative while maintaining six other insurers as negative. The negative outlook was based on the possibility of a reform package passing, which is likely to have negative implications on commercial insurers.
Medicare and Medicaid reimbursement rate levels also continue to be in jeopardy. Medicare did not include any reductions in inpatient reimbursement rates for 2010, but this could change. The stimulus bill helped maintain Medicaid reimbursement this year, but with state budgets under pressure, there are likely to be cuts.
Meanwhile, nonprofit hospitals' predicament may be worse when you consider the dismal performance of investments last year. "There are a few issues on the not-for-profit side that the for-profits don't have," says Diaz. "The not-for-profits have seen declines in their investment holdings and have issues around funding pension liabilities."
There is some good news in all of this. Moody's believes many for-profit hospital operators will continue to grow their cash balances as they cut back on capital spending and do fewer acquisitions.
