The health insurance industry is sending thousands of its employees to town-hall meetings and other forums during Congress's August recess to try to counter a tide of criticism directed at the insurers. Among the throngs of Americans crowding the sessions, the industry employees come armed with talking points about the need for bipartisan legislation and the unintended consequences of a government-run health plan to compete with private insurers. A "Town Hall Tips" memo written by America's Health Insurance Plans warns people attending the meetings to expect harsh criticism directed at health plan employees and asks employees to remain calm and not yell at members of Congress.
Senate Democrats said they were fleshing out plans to pass health legislation, particularly the option of a new government-run insurance program, with a simple majority, instead of the 60 votes that would ordinarily be needed to overcome a filibuster. After consulting experts in Senate rules and procedure, the Democrats said they were increasingly confident that they could create a public plan in a way that would withstand challenges expected from Republicans.
Senator Joseph Lieberman of (I-CT) urged President Obama to postpone many of his initiatives because of the economic downturn. Lieberman said lawmakers don't need to resolve all of the health system issues now, but need to get started. The places to begin are insurance market and health delivery reforms, he said.
Massachusetts General Hospital is creating one of the first comprehensive programs in the nation to provide specialized medical care to adults with autism, a group whose numbers are poised to surge as tens of thousands of children diagnosed with the developmental disorder grow up. The hospital plans to announce that it will receive $29 million in part to add a major adult component to its pediatric autism program. The money will also allow the hospital to expand its services for children with autism, who now wait up to a year for an appointment, conduct extensive research, advocate for patients, and train physicians.
How do you ensure that mission and training are locked together? Debra A. Canales, executive vice president and chief administrative officer at Trinity Health in Novi, MI, says it begins with defining a set of guiding behaviors so that employees know what success looks like and how they can live the values of the organization.
Greg Walton, chief information officer at El Camino Hospital in Mountain View, CA, shares strategies CIOs can use to survive the recession while designing for digital care. For example, organizations should factor in the amount of electricity the hospital of the future will need, as well as, the amount of heat all that electricity will generate.
Quality improvement is something that UMASS Memorial Medical Center (UMMMC) has been focusing on since 2007 when Robert A. Klugman, MD came on board as senior vice president, chief quality officer, and medical director of managed care. One of his main focuses was changing the existing role of physician quality officers (PQO) from the traditional role to a new and improved role.
At the time, the traditional PQO was responsible for a clinical department and there was a tremendous variation in the amount of work each one was putting into improving the healthcare system. This variation was one of the main reasons why Klugman wanted to change the existing structure.
"A key component is engaging clinicians in this type of quality improvement effort, and getting them on board with quality improvement work," says Klugman.
Klugman decided to focus on a multi-disciplinary role for PQOs in the quality department. The PQOs would focus on systems improvement and be centralized within one multi-disciplinary office rather than focus on their separate clinical departments.
Even now, two years after Klugman instituted the new PQO model, physicians, other facilities, and national organizations continue to show interest in this model.
"Our model has been very successful," says Klugman. "The PQOs are now highly regarded by their colleagues which has fostered increased engagement by the medical staff in quality improvement initiatives. This is a big challenge in every organization."
Traditional vs. new
Many facilities have the traditional model in place, where the chief medical officer handles medical staff issues, credentialing, and privileges and the chief quality officer dedicated to handling quality improvement issues. Both the chief medical officer and the chief quality officer report to the chief executive officer. It quickly became apparent to Klugman that this structure wasn’t working at UMMMC.
"The lone ranger can't really do the work, particularly in larger organizations, without the engagement of the medical staff," says Klugman.
Continuing with the traditional model, each clinical department is responsible for quality improvement work in its own department. The department chair appoints a person in charge of quality improvement, who may not have had formal training and works only in his or her own department. Quality improvement work is not coordinated or organized between departments.
Klugman saw two major problems with this model:
Variability in the energy, effort, and guidance PQO received to accomplish tasks due to multiple quality departments that were not integrated
Fragmentation in the division of work between departments
Klugman wanted to ensure that UMMMC's quality improvement work continued to evolve along side healthcare as it becomes more patient centered.
"There is really a major push to take care from the bedside, and the patient perspective, and disease perspective, rather than divide it up into which department best fits," says Klugman.
Klugman's model was devised to recruit physicians who wanted to work as a PQO and was not based on departmental assignment.
"The PQO would work for the department of quality, but not necessarily in the department related to their medical discipline," says Klugman.
PQO for hire, training, and work
Klugman and a selection committee made up of department chairs, nursing leaders, quality improvement experts, the chief quality officer, and the medical center president helped sort through the 25 in-house applicants for the PQO positions.
The PQOs were and are currently required to:
Be practicing physicians to bring clinical experience to quality improvement work
Have excellent interpersonal and team building skills
Have experience with change management
Resolve issues through consensus building
Demonstrate a passion and commitment to improve clinical performance
From the 25 original applicants, seven were chosen. They came from surgery, internal medicine, pediatrics, pediatric emergency medicine, obstetrics and gynecology, family practice, and cardiology.
The PQOs were required to take four 2-hour sessions of Quality College. The Quality College is a program designed by UMMMC, to educate the physicians on quality and patient safety, says Klugman.
The PQOs are then assigned ongoing projects in quality improvement processes and work closely with members of infection control, pharmacy, nursing, radiology, and risk management.
PQOs are assigned tasks based on their particular interest, and which PQO is best suited for the job. For example a surgeon PQO would be assigned to the National Surgical Quality Improvement Program.
Making the change and continuing forward
Obstacles are always bound to arise during the implementation of a new process, and this was no exception.
During the initial implementation of the PQO model, there were some resistance from the departmental administration and some staff members, says Klugman. With the new model in place, department leaders would have less control over their PQOs because the PQO would now be reporting to the chief quality officer.
Now, two years later, staff members' reactions are a little different.
"In a recent quality meeting with all the departments of quality and administration, it was universal by all the chairs that this was a great model and a (huge) improvement from the traditional model," says Klugman. "The PQOs have been very visible as leaders, experts, and role models. They have been very effective in engaging other MDs in working on improvement of all of our big quality improvement initiatives like rapid response, national patient safety goals, and cardiac improvements."
A statistical review of 82 individual research studies shows that nonprofit nursing homes may be delivering on average higher quality care in several categories than for profit nursing homes, according to researchers writing in a new study of the online version of the British Medical Journal.
The researchers began with a search that initially yielded nearly 9,000 citations from between 1965 and 2003. This was narrowed down through a systematic review to 82 individual studies that compared four quality of care measurements in thousands of nursing homes, mostly in the United States (with some data from Canada and Taiwan).
The four quality categories examined were:
Number of staff per resident or level of training of staff
Frequency of use of physical restraints
Prevalence of pressure ulcers or bedsores
Regulatory or government deficiencies
The researchers masked the studies' results before determining eligibility.
In 40 of the 82 studies, the researchers' meta analysis found that nonprofit facilities delivered higher quality care than for profit facilities in two of the four most frequently reported quality measures: more or higher quality staffing and less prevalence of pressure ulcers. The results also suggested somewhat better performance of the nonprofit homes in the other two quality measures.
About 1.5 million people currently reside in nearly 16,000 nursing homes in the United States, and more than 3 million Americans will spend at least some time in a nursing home this year, according to the Centers for Medicare and Medicaid Services. About two thirds of U.S. nursing home residents live in for profit facilities.
The findings have significant patient care implications, the authors said. The results suggest U.S. residents would receive about 500,000 more hours of nursing care per day if nonprofit institutions replaced for profit nursing homes.
The finding that not-for-profit facilities provide better care has been a common finding in many recent articles and studies, said Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy in Washington, DC. "We've known for a long time how understaffed nursing homes are. It's an incredibly serious problem."
"What jumped out at me the most was their finding that if all nursing homes in the U.S. provided the level of staffing that not-for-profits facilities do, we'd have more than a half million hours per day more of staffing," she said. "It's a stunning number of hours... and we wonder why the quality of care is as poor as it is in too many places."
Whether in the halls of Congress or in town hall meetings, the debate should not be whether Congress keeps its hands off Medicare, but how it should regulate Medicare—and do it in the way that provides the maximum benefits to the public, said Eugene Steuerle, vice president with the Peter G. Peterson Foundation, at a conference held Thursday by the journal Health Affairs to address healthcare reform.
The fact remains that "Medicare and health spending are on an unsustainable path," said Steuerle, an economist. However, no major Medicare reform currently is on the table as part of healthcare reform—nor is it really likely to appear during 2009.
For the most part, Medicare reforms that are being discussed under healthcare reform are "fairly modest," with most of them relating to providing information that might be to control costs later, he said. However, next year may be a different story when Congress realizes it is going to have to start addressing these deficit issues, he said.
What is fact is that the tax rate that's required to support Medicare is creeping up, Steuerle said. For instance, in 1975, the rate was about 2%, and in 1990 it was 4%. By 2010, it will reach 7%, and in another 20 years, it could jump to about 14% at current rates. With no changes by Congress, that would mean that it would take almost the entire Social Security tax rate (now 15%) just to pay for Medicare alone.
On another note, in the midst of the healthcare debate, "you hear so many people correctly say: 'This looks more like a sick care system than a healthcare system,'" said Darrell Kirch, MD, president and CEO of the Association of American Medical Colleges in Washington, DC.
"The colleagues that I speak with know that being paid to intervene when illnesses have gone too far is not what they went to medical school to do," Kirch said.
Many of these colleagues say that they are ready to consider alternative payment method and to start focusing on value and outcomes—as opposed by volume. However, this is "unfortunately being talked about only peripherally in this debate," he said.
One issue that has become controversial in the healthcare debate is end-of-life care. Christine Cassel, MD, president and CEO of the American Board of Internal Medicine, has found this ironic in a way.
Through working with patients, Cassel has found that many people want to have a sense of control and dignity and they are concerned about being burdens on a family--both financially and emotionally.
Jerald Winakur, MD, a geriatrician, who also teaches at the Center for Medical Humanities and Ethics at the University of Texas Health Science Center at San Antonio, said none of the proposals are suggesting that "doctors substitute advance care planning for medical care."
"No one is proposing death panels or outside experts to decide who lives and dies. I would not be a part of such a system nor would any physician I know," he said.
But of the flip side, "any system that refuses to reward the work of healthcare professionals for doing advance care planning and conferencing with families during difficult times is pre-ordained to be cold and bureaucratic, sterile, and unempathetic," Winakur said. "It will subject our frail elderly and anyone who finds him or herself with an end-stage disease at the end of their lives to inappropriate, unnecessarily expensive, and possible futile care."
As the global healthcare world gets smaller, it is more important than ever for providers to consider business opportunities outside of their home country's borders.
With that in mind, organizers of the Health Care Globalization Summit seek to help executives learn how to maximize their opportunities in the global healthcare marketplace. The summit, taking place from Nov. 10-13 in Miami, is being produced by Consumer Health World under the direction of Medicatree International.
"We think that the globalization of healthcare is here—it's much bigger than anything that healthcare in the United States has ever seen, including the early days of Ehealth," says Skip Brickley, CEO of Medicatree International.
"There are three principle areas driving healthcare today—outside of legislation—and that is consumerism, Web enablement, and the globalization of healthcare. We think these will be most transformative, impacting areas on healthcare in the next several years and we make our programming around these three tenants."
This is the sixth such global healthcare summit Medicatree International has been involved in. Brickley says organizers work closely with high-level industry leaders to develop the program in an effort to ensure topics are relevant to the industry.
"Always, our goal is to produce high-level content bringing thought leaders together with high-level decision-making delegates and putting them into an educationally rich environment that is prone to transaction of business," Brickley says.
And having a strategy to compete in the global healthcare business is more important than ever. As an increasing number of patients all over the globe have the means and incentive to find the highest quality care at the lowest cost—no matter where it is—and global providers could be missing out on a large patient base if they ignore the medical tourism trend.
The growing number of healthcare providers outside of the United States that offer high-quality procedures is increasing competitiveness among hospitals, Brickley says. He compares it to the market dynamics that changed the automotive and electronic industries as global companies expanded their expertise and cut in to U.S. dominance.
Brickley notes that "we have a session, in fact, that is our closing keynote panel: Will U.S. providers meet the competition from international specialty surgery centers and their rapid advances in healthcare delivery, or will the U.S. providers suffer the same fate as the automotive industry?"
But he is quick to note that the focus is beyond just the medical tourism perspective. One whole day of workshops at the conference will focus on quality and safety, and there will be interactive workshops between purchasers and international providers, for example.
While there have been signs of improvement in recent weeks, leaders in the healthcare industry can still learn from their fellow executives on how to better attract patients and maintain business. And why restrict these strategies from those within their own country? No doubt lessons can—and should—be taken from all over the globe.
"The conference frames the issues, opportunities, and potential responses for both U.S. and international healthcare, travel, and health technology stakeholders—including domestic and international providers, U.S. employers, health insurers, and economic development executives recognizing the value of attracting patients to their facilities," Brickley says.
