Congressional Democrats said that they intended to push the Obama administration to back away from its deal with the drug industry to cap its share of the costs in a healthcare overhaul. A spokesman for Speaker Nancy Pelosi said she stood by her position that the House was not bound by any such agreement. Pelosi supports House efforts "to squeeze more money out of the system, including from the pharmaceutical industry," her spokesman, Nadeam Elshami, said in a statement.
Larry Schreiber has been named president of Anthem Blue Cross and Blue Shield in Wisconsin. He replaces Steve Martenet, who was appointed to lead specialty insurance product sales for Anthem's parent company. Schreiber, 46, will be responsible for the management of all sales, marketing, and underwriting functions for small and large group accounts in Wisconsin, and serve as the primary contact for state regulators. Schreiber will also oversee Anthem's social responsibility activities dedicated to promoting health and wellness throughout Wisconsin. He is currently vice president and general manager for UniCare, a health benefits company based in Chicago.
Karen S. Rohan, 46, became president of Magellan Health Services effective Aug. 1. She is responsible for the strategic direction and profit and loss of Magellan's existing business units and, with the close of the acquisition, the company's First Health Services business. Rohan has more than 18 years of experience in the healthcare industry and was most recently president of the Group Disability, Dental and Vision Care businesses of CIGNA Corp. Separately, Magellan has begun to implement its succession plan for the leadership of its ICORE subsidiary. Alan Lotvin, MD, 47, the division's president, will ultimately succeed Raju Mantena as CEO. Having fulfilled his obligations under the ICORE purchase agreement to manage the business for three years, Mantena, 41, announced he intends to leave full-time employment with Magellan when management feels comfortable that the leadership transition is complete.
Richard J. Liekweg has been named group president of BJC HealthCare and president of Barnes-Jewish Hospital and Barnes-Jewish West County Hospital, effective Sept. 14. He comes to St. Louis after six years as CEO and associate vice chancellor for the University of California, San Diego Medical Center. Barnes-Jewish Hospital, a 1,252-bed nonprofit academic hospital, is the largest hospital in Missouri.
Cardinal Health has named George S. Barrett vice chairman of Cardinal Health and CEO of its Healthcare Supply Chain Services sector. Barrett, 52, who is currently the CEO of Teva North America, will join the company at the end of January and report to Chairman and CEO R. Kerry Clark. He served as corporate executive vice president of Teva's Global Pharmaceutical Markets since January 2007, as well as CEO of Teva North America since January 2005. He was president and CEO of Teva USA from 1999 to 2004. Also, David L. Schlotterbeck, 60, has been named vice chairman in addition to his role as CEO of the company's Clinical and Medical Products sector.
Joe Dunn is resigning as the CEO of the California Medical Association, but wants to remain with CMA in some capacity. Dunn said he took the step because of family reasons.
Let's be clear. We offer no opinion in the case of Cathy Cenzon-DeCarlo, the nurse who filed suit against Mount Sinai Hospital in New York City for allegedly scheduling her to assist with a midterm abortion, even though she said the hospital knew about her objections based on religious belief. The facts in the complaint will likely be contested by the hospital. Let the lawyers sort it out.
However, the lawsuit raises a timely reminder of the importance for all healthcare providers to have clear procedures in place for such a scenario. Can a strong code of ethics and practical policies eliminate the tough moral dilemmas that healthcare professionals have to confront? Or, are tough moral dilemmas simply inevitable, given the life-and-death decisions that are part of the job?
"You can ameliorate them. You can figure out ways to manage them. I don't think you can eliminate them," says Mary Jean Schumann, RN, chief programs officer for the American Nurses Association. "My own experience in being a supervisor in a variety of settings where there are times when there is a conflict is clearly you try to accommodate the staff person when you can. Usually you can work that out."
Now might be a good time to meet with your CNO, management staff, and staff nurses to ensure that everybody is familiar and comfortable with your code of ethics, and that everybody is working off the same set of ethical principles on abortion, just as they would for issues like patient privacy and conflict of interest. Schumann says questions like those raised in Cenzon-DeCarlo's suit should be plainly and assertively addressed. "One of the pieces that should be addressed in policy is, when there are such circumstances, what is the procedure for getting those addressed so that if a nurse has an issue around something like this there is a process in place by which they inform their supervisors that they have a concern?" Schumann says. She also recommends that healthcare organizations make clear their policy and employee obligations during the interviewing and hiring process for new nurses and other healthcare professionals.
While it's up to the healthcare organizations to provide a strong and clear set of guidelines, Schumann says nurses also have a responsibility to determine if their moral or religious believes could create a barrier to care. The primary responsibility of a nurse is the safety and health of the patient. She says nurses who object to abortions that may be necessary to ensure the health of patients should go into a healthcare field that minimizes the risk that they will be forced into such a compromise. "At some level, you have to say to an individual who has that strong of a belief, 'if you feel that strongly, why are you working in this environment?'" Schumann says. "The nurse is responsible at the end of the day for that decision. Nobody is putting their feet to the fire that they have to work there. Typically, you would say 'you need to find a different place to work if it is that hard for you.'"
Cenzon-DeCarlo's suit centers around abortion, but Schumann notes that your healthcare organization's guiding principles should be broad enough to include other grave moral questions, such as end-of-life care, which she believes occurs far more frequently than abortion. "Everything works well for an end-of-life situation when the patient, the family, the doctors, and the nurses are on the same page," she says. "But when they aren't all in agreement conflict is inevitable and there need to be ways to sort this out and a policy and procedure for how you do sort them out. It's inevitable but there should be ways to deal with it."
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A "hunkering down" mentality has crept into boardrooms and executive suites across the nation.
Recently, healthcare organizations have spent time and energy looking for ways to shave costs. Layoffs of valued employees have followed, and in extreme circumstances, entire service lines are being looked at as a way to trim the fat as reimbursements have declined.
But cutting the fat will only get you so far, says Matt Krathwohl, executive director of performance at Memorial Hospital South Bend, and featured "Culture" panelist at the HealthLeaders 09: Hospital of the Future Now conference in October. It's a short-term solution to a long term problem, which is to say, not a solution at all.
Instead of focusing on cost-cutting, Krathwohl and the executive team at South Bend believe that the independent hospital's long-term survival depends on innovation. To that end, in conjunction with South Bend's board of directors, Krathwohl has developed a program called Innovisits, in which key hospital employees take structured visits to companies outside the healthcare industry to learn different ways of approaching problems that are common to all organizations.
"That's one of our goals--to bring strategies from outside healthcare to healthcare," he says.
Teams of 3-4 people have visited such longstanding business luminaries as Procter & Gamble and General Electric, "but we've found that small companies are much more nimble," he says. Not to mention that they are more similar in size to South Bend as well
One of the hospitals board members is also on the board of a community bank which had done pioneering work at one of its branches in developing a positive and rewarding customer experience program.
"They're a service business, as is healthcare, so learning the things they did has helped us," Krathwohl says. "We took a team of 3-4 people, talked to the team members of the branch and learned from them about how they are more competitive now."
In service to the innovation goal, South Bend has created an "innovation center," called the Day of Innovation Café.
"Say you get back from another conference and you've heard some great innovators like Tom Peters or Jack Welch," says Krathwohl. "But then you get back to your desk and it's back to business."
"So what do you do with that information? How do you implement change? We help them translate."
The hospital has also developed an "Adventure Center," "where we seek strategic relationships with companies inside and outside healthcare. For instance, he says, "why do we want to build back-end systems when we could find a strategic partner?"
Why indeed? Anyone can cut costs. It takes leaders to innovate your way to a solution to expensive problems.
The economic recession probably brought healthcare CEOs closer to their organizations' day-to-day activities. New federal HIPAA laws should have too. Daniel Nutkis, CEO of The Health Information Trust Alliance (HITRUST), believes compliance with HIPAA privacy and security starts from the top.
"Our experience shows that the more executive management and the board of directors are engaged in understanding the challenges and issues the more diligent the organization is in addressing information protection," says Nutkis. "HITRUST has seen a significant increase in the number of organizations that have added information protection as a component of their overall corporate responsibility measure or corporate philosophy."
HealthLeaders Media caught up this week with Nutkis for a Q&A about HIPAA privacy and security. The following are some highlights. The full Q&A can be found on the HCPro, Inc. HIPAA Update blog.
HealthLeaders Media: Federal laws on HIPAA changed with the signing of the American Recovery and Reinvestment Act (ARRA) of 2009. Did you see this coming?
Nutkis: ARRA is pushing for the broad adoption and utilization of health information systems, electronic health records, and electronic exchanges of health information. ARRA also recognizes the importance of information security in meeting this objective. Efficiency and reduced costs for consumers was the driver. HITRUST recognized this long before the signing of the bill, and we continue to be an advocate for more effective and efficient information protection in the healthcare industry.
HealthLeaders Media: What were the major flaws in HIPAA rules before the signing of the ARRA?
Nutkis: The primary issues with HIPAA are a lack of clear requirements and enforcement by government agencies. ARRA allows for a risk-based implementation of the safeguards outlined in HIPAA, which are themselves subject to interpretation, meaning there is no consistent application of security controls across the industry. While there are penalties for non-compliance, the industry rarely saw repercussions and subsequently rarely took HIPAA serious. While ARRA does not necessarily provide the prescriptive security requirements needed in HIPAA—like we find with PCI https://www.pcisecuritystandards.org/—it does provide focus for covered entities on breach notification, securing PHI, and business associate compliance.
HealthLeaders Media: What kind of an impact does the move to electronic health records have on HIPAA privacy and security?
Nutkis: The impact from EHRs comes in the form of increased focus on privacy and security. It is widely known to the general public that this is the direction the healthcare industry must go to contain costs and increase efficiency in healthcare. However, without proper security and assurance that personal health information will be kept private, consumers will be no more willing to share their health information electronically than they would their bank account or credit card number.
HealthLeaders Media: How should healthcare facilities be reacting right now to the new HIPAA laws in the Health Information for Economic and Clinical Health (HITECH) Act?
Nutkis: Healthcare organizations will need to revisit and adjust their information security governance practices and make additional areas of investment to align with the new requirements. HITRUST recommends that healthcare organizations focus on the following key areas for their security strategic plans over the next 24 months:
Develop and implement an overall compliance strategy: Update policies, processes, and technologies to manage and document compliance efforts
Realign policies: Ensure that internal policies, standards, and procedures are aligned with regulatory requirements
Perform a gap analysis: Conduct a gap analysis of existing security practices against HIPAA and new regulatory requirements
Develop a roadmap for compliance: Develop a plan outlining responsibilities, budget, and timelines to address gaps identified during the assessment
Maintain an audit ready state: Based on recommendations by the OIG in 2008 and the new legislation, HHS will more assertively perform compliance audits in the upcoming years.
HealthLeaders Media: What are some weaknesses you see with healthcare facilities as they attempt to comply with HIPAA privacy and security?
Nutkis: During the development of our Common Security Framework (CSF), a certifiable framework that any and all organizations in the healthcare industry can implement and be certified against to reduce risk, the professionals from healthcare organizations of all segments provided us with input on the top issues affecting the industry resulting in the most severe breaches and loss of covered information. These include:
Insecure and/or unauthorized removable transportable media and laptops (internal and external movements)
Insecure and/or unauthorized external electronic transmissions of covered information
Insecure and/or unauthorized remote access by internal and third-party personnel
Insider snooping and data theft
Malicious code and inconsistent implementation and update of prevention software
Inadequate and irregular information security awareness for the entire workforce
Lack of consistent network isolation between internal and external domains
Insecure and/or unauthorized implementation of wireless technology
Lack of consistent service provider, third party, and product support for information security
Editor's note: This is the first of a two-part series from our interview with Nutkis. In the next installment: The importance of business associates complying with the HIPAA Security Rule.
On quality measures, hospitals treating larger numbers of the poor did not perform as well as hospitals serving more affluent populations back in 2003. But by 2006 that changed.
When offered a financial incentive from the federal government's three-year pay-for-performance incentive demonstration project, mortality rates went down and many quality measures improved closer to the level of their counterpart hospitals treating more wealthy patients. The poorer hospitals were able to narrow the gap.
That's the latest news from the third year of the Premier Hospital Quality Incentive Demonstration (HQID) project, which has tracked performance and outcome statistics for 250 hospitals in 36 states on 30 quality measures. The measures deal with care of patients with five conditions: Community-acquired pneumonia, heart attack, heart failure, coronary artery bypass surgery, and hip or knee replacement.
Safety net and non-safety net hospitals are evaluated in both urban and rural parts of the country.
"We are delighted that the demonstration has produced evidence that value-based purchasing can improve the quality of care for Medicare beneficiaries," says Mark Wynn, director of payment policy demonstrations for the Centers for Medicare and Medicaid Services.
Pay-for-performance incentives to improve quality can be applied across the country with similar success, says Susan DeVore, Premier's president and CEO.
"Current value-based purchasing proposals are structured appropriately to allow all hospitals to succeed, regardless of size, location or patient/payer mix," she says. "We are confident that if our recommendations are followed, VBP will be an effective national reform that will improve quality, reduce variation and avoid unnecessary costs."
The HQID project is the basis for CMS' proposal to Congress for a national pay-for-performance program and has been mentioned by members of the Senate Finance Committee and the Democratic Blue Dog coalition.
However, according to Premier officials, concerns were raised that if imposed as a national standard, the pay-for-performance programs would reward only wealthier hospitals. This research refuted that belief by discovering that hospitals regardless of their size or location can succeed attaining pay for performance.
For example, the research found that overall, safety-net hospitals treating heart-attack patients had an 88.8% quality score in 2003, but in 2006 had improved to 95.2% or by 6.4%. Non-safety-net hospitals started out higher, at 90.7% but improved only 5.5% to 96.2%.
CMS has handed out $24.5 million to top performers, and this year, 112 of the 250 hospitals scoring in the top 20% in each of the project's five clinical areas will receive $7 million, a total of 206 awards.
The top 10% scoring hospitals receive a 2% incentive payment per clinical area. Hospitals between 11 and 20% receive a 1% incentive payment. Also, all hospitals in the top 50% of each clinical area receive public recognition on the CMS Web site.
The amounts of each hospital's award will be made public later this month.
Jack Garon, MD, chief medical officer for Mount Sinai Hospital in Chicago, a 280-bed disproportionate share hospital that treats large numbers of the poor, says that in reality, the money was not what propelled his hospital's efforts to improve quality.
"The money is not enormous or staggering. In fact, it isn't enough of a motivator to do this just for the money," he says. "You're also motivated to be able to say you're in the top 10%."
At his hospital, making sure that quality measures were consistently met became like a competitive exercise that was a dynamic and transparent look at how staff was performing.
"We created a scorecard that enabled us to look at these measures at a glance," he says. "We color-coded it. Being in the top 10% would be green. Yellow was top 50%, and red meant we were in the bottom 50%."
Safety net hospitals, also called DSH or "Pickle" (after a Texas congressman) facilities, are defined as those qualifying for disproportionate share money under one of two definitions. For example, they can qualify by being in an urban area with more than 100 beds and receive 30% of net inpatient revenue from state and local revenues for indigent care.
In the category of heart failure, safety net hospitals started out low on adherence to quality measures, 68.4% but improved to 86.3% after three years. Non-safety net hospitals also started out low, at 72.4%, and improved to 88.6%.
In hip and knee replacement, safety net hospitals started at 86.8%, but improved to 94.7%, a 7.9% improvement, while non-safety net hospitals started at 89% and went to 95.5%, a 6.5% improvement.
Scores are achieved by, for example, making sure patients with an acute myocardial infarction receive an aspirin at arrival and that aspirin is prescribed at discharge.
For patients with pneumonia, appropriate care would be in making sure each patient received his or her initial antibiotic within four hours of arriving at the hospital door. For patients with a hip or knee replacement, all would be assessed for their risk of developing a hematoma or hemorrhage.
Also, inpatient mortality rates and whether the patients had to be readmitted for the same illness within 30 days are both scored.
"The research found that hospitals, regardless of size or location, can succeed in value-based purchasing."
The success of value-based purchasing programs like this one organized by CMS and Premier are destined to become much more widespread with a variety of initiatives under discussion in health reform efforts.
Officials for both CMS and Premier suggest three lessons for how to implement a successful national pay-for-performance program:
Phase in payment incentive programs gradually to give hospitals serving higher numbers of uninsured and the poor more time to adjust.
Provide technical assistance and resources to hospitals that fall below national thresholds.
When a hospital's performance scores dramatically improve, reward that dramatic improvement, even if the hospital continues to fall below goals, to create incentives to continue to make rapid improvements.
Overall, improvements in quality of care saved the lives of an additional 2,500 patients who came to the hospital with a heart attack, and all patients received approximately 300,000 additional recommended evidence-based clinical quality treatments. They included smoking cessation, discharge instructions and pneumococcal vaccine.
The demonstration project has been extended another three years and will be extended to new measures, such as consumer assessments, surgical care improvements, and care of patients with ischemic stroke.
