Faced with data showing Dallas doesn't give good value for money in healthcare, North Texas medical, insurance, and other business leaders are discussing a transformation to curb spending and improve quality. The talks involve archrival hospital chains Baylor Health Care Systems and Texas Health Resources as well as other hospitals, physician groups, the Greater Dallas Chamber of Commerce and insurer Cigna HealthCare.
As the nation faces a political showdown over health insurance reform, insurers worried that an overhaul could hurt their bottom line are funneling a wave of cash to members of Congress. Health and accident insurers and HMOs have spent more than $40 million on current members of Congress over the past 10 years, according to the Center for Responsive Politics, which analyzed Federal Election Commission data.
Atlanta-based St. Joseph's Hospital recently notified patients that it may end its relationship with medical insurance giant United Healthcare, effective Aug. 7, unless a new contract is reached. United Healthcare, which insures more than 1.5 million Georgians, sent a similar letter to its customers. The contract has reached its expiration before but the two parties agreed to extend it.
While town officials say Winchester (MA) Hospital's proposed expansion has been subject to extraordinary governmental scrutiny, opponents say few residents still fully understand the plan. Despite many government meetings, serious problems with the project have either gone ignored or unresolved, according to opponents.
State officials have announced that Massachusetts will receive $500,000 in grant money to support the transformation of 14 community health centers into patient-centered medical homes. Among the centers selected for the program are the Greater Lawrence Family Health Center and the Cambridge Health Alliance's Revere Family Health Center.
As federal health agencies seek to hand out stimulus funds to research the effectiveness of various medical treatments, they will include projects that look in part at the cost of drugs and other treatments. Obama administration officials have said they want to use stimulus funds to help doctors and patients choose more-effective treatments and ultimately, help rein in rising healthcare costs. The Agency for Healthcare Research and Quality, which has $300 million to spend on comparative research, said it would increase funding to projects that focus on arthritis, cancer, and 12 other conditions that are often costly to treat.
Eli Lilly has released a new "faculty registry," a list of payments to all the doctors who served as consultants in the first quarter of this year. The list is part of the company's efforts to increase transparency, according to Lilly representatives.
Setting itself apart from the American Medical Association, a coalition of 450,000 doctors in six physician groups is touting its new campaign, "Heal Health Care Now," to strongly back health reform and to urge their patients to do likewise.
The group of mostly primary care practitioners wants people to let their lawmakers know when they come home for August recess that health reform should be the nation's top priority.
"We want everybody to have healthcare, universal care, so nobody should face a personal catastrophe or bankruptcy when they have a medical event that can ruin a family's future," says Ted Epperly, MD, president of the American Academy of Family Physicians, a 94,000-member group, and a doctor in Boise, ID.
Epperly called the campaign "a viral video," with YouTube and other sorts of Internet-related messaging. "The goal is to have over one million people see it and spread it virally" across the country.
The effort does not speak to specifics of what should be in the health reform bill, only that there should be reform. More to the point, the campaign strives to enact a national policy of universal coverage.
"We don't want to get into the weeds with all the unique aspects because it's so distracting," Epperly says. "We're taking a 75,000-foot view: Do you want healthcare reform or do you not? We want people and doctors to tell their lawmakers that they do."
Much of their emphasis for changing the current system focuses on reorienting the system to a prevention model. Without health reform now, he says, patients "will live sicker, and they will die younger."
Epperly says these physician groups support a public plan, but they want one that pays higher rates than Medicare and does not mandate that physicians participate; they should have a choice. Reform also should not create a public plan that is so competitive that it forces health insurance companies out of business.
The video idea was launched, Epperly says, as a way of making sure the public understands that the bulk of front-line doctors want health reform. The American Medical Association, which was initially conflicted on the issue and now backs H.R. 3200, has not been as forceful in its advocacy as these doctors would like.
"The AMA is a group that's like the bar scene in one of the first Star Wars movies, it struggles to find its voice, and often is seen as the 'Party of No,' Epperly says.
The video was prepared by the Herndon Alliance, a nationwide coalition of 200 minority, faith, labor, advocacy, business, and healthcare provider groups, including the American Nurses Association, the American Academy of Pediatrics, the American Association of Retired People, the Mayo Clinic, and Families USA.
The group signed a letter that reads in part, "We are confident that the reforms being proposed will allow us to provide better quality care to our patients, while preserving patient choice of plan and doctor."
The group's media campaign is Web-based and includes a three-minute series of vignettes from physicians around the country explaining why the status quo is intolerable.
"Medicine now has been shifted and it's really now more about insurance companies and rules that aren't fair. It's no longer about the patient and the doctor," says Lori Heim, MD of Vass, NC.
It's so crucial to make sure health reform passes this time around, and not befall the same fate as a similar attempt did during the Clinton administration, Epperly says.
"It's so different this time—this is the first time that 47 million Americans have gone without health insurance. We have big businesses going bankrupt and people going bankrupt on healthcare costs," he says.
Arthur Caplan, a professor of bioethics at the University of Pennsylvania Center for Bioethics, says Martin Memorial Medical Center was unfairly criticized after the Stuart, FL hospital chartered an airplane and returned Luis Jimenez, 37, to his native Guatemala in 2003. The hospital had been providing unreimbursed long-term care for the uninsured day laborer ever since he suffered severe head injuries in a 2000 automobile accident that left him partially paralyzed. The hospital placed the value of the uncompensated care at around $1.5 million.
"Those who are outraged over sending him home should try to push for illegal aliens to be covered. Good luck with that," Caplan says. "You can yell at the hospital all you want, but if he was in a public plan they probably would have kept him here because he would have had coverage. In a way, each one of us decided to send him home."
A civil jury in Stuart this week sided with the hospital and rejected claims made by Jimenez's relatives that he was illegally repatriated. Jimenez"s family had sought $1 million to cover the cost of his continuing care in Guatemala, along with unspecified punitive awards to discourage other hospitals from taking similar actions. The case was closely followed by many healthcare and immigration experts because it raises the issue of who is responsible for providing long-term care for illegal aliens who don't qualify for federal or state aid.
While happy with the jury's verdict, Mark E. Robitaille, CEO at Martin Memorial, says he is also disappointed "that the issue of providing healthcare to undocumented immigrants remains unresolved on a state and national level."
"This is not simply an issue facing Martin Memorial. It is a critical dilemma facing healthcare providers across Florida and across the United States," says Robitaille, who was not with the hospital when Jimenez was repatriated. "What is truly unfortunate is that since Mr. Jimenez was first admitted to Martin Memorial nine years ago, nothing has been done to address this issue by our political leadership."
Like Caplan, Robitaille says he's not optimistic that the issue will be addressed soon. "This is an opportunity for leaders at the state and federal levels to find a solution, rather than relying on individual healthcare providers to develop solutions on a case-by-case basis," he says. "Unfortunately, none of the proposed national healthcare reform bills currently being debated in Washington address the issue of how to adequately provide healthcare for undocumented immigrants in a way that is fair and equitable to everyone involved."
Caplan says that, even though Martin Memorial was acting out of financial interest when it repatriated Jimenez, the hospital had fulfilled its ethical obligation to the Guatemalan with the care he'd received for nearly three years.
"When it is an emergency you have to be humane and do what you can do. But once they are stabilized and once they are beyond what the medicine can do, I don't have a problem with them returning him to Guatemala," Caplan says. "If there were more that could be done, they have a duty, even though he is not a paying person, to try and get him care that might help him regain function. But there was no indication that was the case."
"To put it bluntly, there is a difference between transferring someone back home and dumping him back home," he says. "From what I saw in the court discussion, they were closer to transferring than they were to dumping."
Industry experts have repeatedly said that ICD-10 implementation must begin immediately in order for hospitals, health plans, and vendors to meet the October 1, 2013 compliance deadline. But now there is detailed evidence to prove it.
NCHICA and WEDI estimate it will take providers nearly 1,286 work days to implement ICD-10. For vendors, it will take nearly 1,521 work days to complete. And the clock is ticking.
"The NCHICA-WEDI timeline shows graphically that the full time from now to October 2013 will be required to successfully meet the compliance deadline. We cannot continue to delay this effort," said Holt Anderson, executive director of NCHICA in a press release.
For providers, the figure takes into account 256 days to organize the implementation effort. The timeline also outlines 36 months for identifying process improvements (e.g., how hospitals intend to use more specific data to target education or treatment for certain patient populations), 14 months for internal system design/development, 12 months for internal testing, 12 months for vendor code deployment, and 10 months for external testing.
Although the numbers may sound daunting, the writing has definitely been on the wall since CMS' January 16, 2009 publication of the ICD-10 final rule. Hospitals should already be well on their way toward planning for the change.
Hospitals need to realize that adopting ICD-10 isn't a choice and that there won't be any extension or contingency period in which to do so, says Stanley Nachimson, principal of Nachimson Advisors in Reisterstown, MD, and director of the NCHICA and WEDI timeline project.
Failing to comply by the 2013 deadline or to perform adequate internal and external testing could result in delayed or denied reimbursement, Nachimson says, adding that certain delays and problems will be unavoidable. "There may be a period of time where claims are slowed down while everybody gets used to the coding and understands it," he says.
These delays are something that nobody wants to think about right now, Nachimson says. "Hospitals have such thin margins these days. Even a 1% interruption in their cash flow may be very difficult to manage," he adds.
Managing an ICD-10 implementation among other larger and costly initiatives is also challenging, says Shereen Martin, RHIA, MSA, director of HIM and privacy officer for Washington County Hospital in Hagerstown, MD. Many hospitals nationwide will be focusing their efforts on recovery audit contractors, leaving few resources to devote to ICD-10, she adds.
Washington County Hospital is currently in the midst of deploying an EHR in its ED, implementing computerized physician order entry, and preparing for complex RAC reviews in August. As with most other hospitals, Washington County must first determine how it will fare with RACs before deciding how soon it will turn its attention to ICD-10, she says. "Coding managers will be dealing with both issues [RACs and ICD-10]."
Starting as early as you can—particularly from a budgeting perspective—will only help you in the long run, Nachimson says. "If you want to get this done, you need to do some of it now and some of it in each of the next few years," he adds. "Otherwise, you're going to get to 2012 and be faced with such a large resource or budget need that you're not going to be able to make it."
As hospitals begin to think about how to qualify for EHR incentives under ARRA, they also need to be asking how vendors plan to accommodate ICD-10. Hold vendor representatives responsible for their own portion of the timeline, Nachimson says.
Although vendors may be able to provide some education, hospitals need to think about how ICD-10 will affect their business processes. For example, how will hospitals ensure that physician documentation will be specific enough to meet ICD-10 standards? How might quality measures or clinical guidelines change to accommodate the new codes? Will health plan coverage for certain tests change so that only certain severe conditions will be deemed medically necessary? These questions are only the tip of the iceberg in terms of potential ramifications of ICD-10, Nachimson says.
