We're half way through 2009 and there is little indication that the last six months of the year are going to be better for hospital employment than the first six months.
In fact, there is a chance that things could get a lot worse well into 2010 as the recession that officially began in December 2007 continues to squeeze the nation. Hospitals already are in the second year of learning to live with tanking portfolios, soft patient volumes, and negative overall margins. Many have already cut staff as a last resort this year. How much longer can they operate before even more widespread and larger layoffs become unavoidable? What happens when they're forced to cut budgets that are already lean?
That's what they're contemplating in Pennsylvania, where Gov. Ed Rendell and the state Senate are at loggerheads over how to cover a $3 billion budget gap. Rendell, in his budget, has proposed cutting $78 million for hospitals. The Senate wants to cut about $280 million in hospital payments, which hospital advocates say would threaten more than 13,000 hospital jobs, directly and indirectly, in affected communities.
"Job cuts of this magnitude will translate into reduced access to hospital care for Pennsylvania's citizens as funding is eliminated for trauma centers, burn centers, obstetrical and neonatal services, medical and health professional education, small and rural hospitals, and hospital services for uninsured adults," says Carolyn F. Scanlan, president and CEO of The Hospital & Healthsystem Association of Pennsylvania.
HAP, which represents about 250 acute- and specialty-care hospitals in the Keystone State, estimates that as many as 4,000 hospital workers have already been laid off statewide since last September in anticipation of the current budget woes.
"Hospitals have already taken significant steps in response to the ongoing recession," Scanlan says. "Before the state budget cuts were proposed, half of all hospitals were already facing challenges in meeting their day-to-day financial obligations; more than eight of 10 hospitals had, or were considering, reducing staff; and nine of 10 hospitals had reduced capital spending for building improvements, renovations, or new medical equipment."
Scanlon says Pennsylvania's hospitals have already made "every effort" to reduce expenses and find savings, which means that the only place left to cut is staff. "Hospitals are running out of options," she says. "With hospital total margins solidly in negative territory, reducing staff is moving from the last resort to the only option remaining. This will be devastating for hospitals, their employees, their patients, and the communities they serve."
Pennsylvania isn't the only state that faces the potential for layoffs in the hospital sector because of state-level budget cuts. The Washington-based Center on Budget and Policy Priorities says that at least 48 of the 50 states have had to deal with or are facing budget shortfalls. California is struggling with an unthinkable $24 billion shortfall, and has issued IOUs to creditors.
Looking ahead to 2010, it doesn't get much better. Tax revenues will be down because there is no indication yet that the economy is on the uptick. An anticipated third straight year of declines in state and local sales, income, and property taxes means that something will have to be cut. The cuts will have to come from somewhere, and healthcare—usually in the form of Medicaid funding—is often one of the biggest targets in states' budgets. Brace yourselves.
Note: You can sign up to receive HealthLeaders Media HR, a free weekly e-newsletter that provides up-to-date information on effective HR strategies, recruitment and compensation, physician staffing, and ongoing organizational development.
With Congress coming back today from the July 4 recess, time will be short and work will be long as the proposed deadlines for completion of healthcare reform legislation mark-ups loom. In the House, July 31 is the target date; in the Senate it's August 8.
Can they make those deadlines?
In the House, key issues—including a public health insurance option, health exchange, and caps on out-of-pocket spending—have been included in a draft bill approved by three House committees. The big questions now on the table: How much will it cost, and how to pay for it?
In the Senate, the costs have had the focus. Before he left town for the recess, Sen. Max Baucus (D-MT), chair of the Senate Finance Committee, announced that the panel's reform package now had "options" that the Congressional Budget Office (CBO) said "would cost under $1 trillion [over 10 years] and would be fully paid for." These options, though, were not specified, but are thought to include lowered insurance subsidies for lower- and middle-income Americans.
The Senate Health, Education, Labor and Pensions Committee went back to the budget drawing board and came up last week with a bill that was scored by the CBO at just over $611 billion over 10 years—a vast drop from the $1 trillion score a week earlier, according to a letter by Sen. Edward Kennedy (D-MA) and Sen. Christopher Dodd (D-CT), who is chairing the committee as Kennedy continues to deal with a brain tumor.
So now come the details. Especially in the Senate, the committees likely will be focused on several key areas—many of which have seen strong disagreement:
Public insurance option: Not surprisingly, topping the list, is a government-operated public insurance option. In their letter last week, Kennedy and Dodd said that they "will not shy away from this challenge . . . we must not settle for legislation that merely gestures at reform."
In the House draft, the public option would be operated within an insurance exchange, would be financed only by its premiums—not by requiring additional government funding—and would be subject to the same regulatory requirements as private plans.
However, GOP opposition appears strong against any type of public plan. Sen. Charles Grassley (R-IA), the ranking minority member of the Senate Finance Committee, said Sunday on CBS, "I am going to make sure we are not going to nationalize health insurance, and a public plan is the first step to doing that."
Employer Mandate. Under a "pay or play" provision in the HELP Committee bill, employers that do not offer their workers "adequate" coverage will be charged an annual fee $750 for each uncovered full-time employee and $375 for each part-time employee. Firms with fewer than 25 employees would be exempt from the mandate. Last week, Dodd called this "a modest cost."
"Such an employer mandate would put businesses out of business," Grassley said. "It would have the same faults that the Clinton bill had 15 years ago, and that's going down the road of not getting healthcare reform."
House GOP leader John Boehner (R-OH), speaking Sunday on Fox television, said the employer mandate—plus the public option—were "deal breakers" with his fellow Republicans. The approach to mandate health insurance through employer and individual mandates would "lead to higher costs, rationing, and lower quality healthcare delivery," he said.
National Health Insurance Exchange. Creation of a new health insurance exchange would make "a transparent and functional marketplace" for individuals and small employers to comparison shop for insurance among public and private insurers, according to the House draft.
The exchange idea, though, has received a wary eye at the state level. For instance, last month, one group of state legislators called the proposed insurance exchange a "federal takeover" of the states' role in regulating health insurance.
Health Co-operatives. In an attempt to reach bipartisan support, the creation of nonprofit health co-operatives has gotten second and third looks in the Senate Finance Committee. Under the proposal made by Sen. Kent Conrad (D-ND) last month, co-ops would initially receive federal startup money but operate independently from the federal government.
However, Sen. Charles Schumer (D-NY), also a member of the Senate Finance Committee, has said that a co-op is not a substitute for a public plan and would be too decentralized to bargain for the best values for insurance buyers nationwide. He did admit, though, Sunday in an interview on CBS that a patient owned cooperative system could serve as a possible point of agreement among committee members on both sides of the aisle.
Comparative Effectiveness Research. The House draft calls for funding a comparative effectiveness trust fund from fees on insured and self-insured health plans.
However, the topic of comparative effectiveness research remains a sensitive issue among Republicans. Just last month, Senate Minority Leader Mitch McConnell (R KY) and Sen. Jon Kyl (R AZ) introduced a bill (S. 1259) to prohibit the use of data obtained "from comparative effectiveness research to deny coverage of items or services under federal healthcare programs."
One of the linchpins of emergency planning is estimating how much personal protective equipment (PPE) staff members might need during an event, such as a pandemic.
HealthLeaders Media reported last month that hospitals in the midst of H1N1 flu responses found their supply chains tested, and certainly PPE—including gloves, respirators, and surgical masks—falls under that concern.
The uncertainty of a pandemic flu outbreak makes it tough to plan for PPE stockpiling. Each hospital plays a different role in its community, and therefore has unique requirements concerning PPE, says Tom Huser MS, CHSP, safety coordinator of emergency management and hazardous materials at Clarian Health in Indianapolis.
"There's no real number," Huser says. "It depends on the facility, the facility's size, location, and population served. If you are a small hospital in the suburbs or rural areas, you may be the only game in town, but the entire population served is probably going to be smaller than a square mile around an urban hospital."
Currently, Huser estimates Clarian has 710,000 pairs of gloves and 5,000 pairs of eye protection locked away in a separate location. To help determine that stockpile, Clarian hired the 3M Company based in St. Paul, MN, to use its surge model to predict how much the hospital might need.
A 3M representative looked at Clarian's population base, estimated 20%–30% becoming ill and requiring hospitalization, and then number-crunched its surge model to determine how many respirators, gowns, gloves, and eye goggles would be needed, Huser says.
Research predicts excess PPE use
A study published in the January 2009 issue of Journal of Hospital Infection observed a British hospital simulating the height of a pandemic in one of its acute medical wards. A study in the January 2009 Journal of Hospital Infection concluded that staff members used more gloves and surgical masks than expected during a pandemic, based on a simulation at a British hospital.
During the 24-hour simulation, 23 workers used 650 surgical masks, 1,200 pairs of gloves, and 750 disposable aprons. Many staff members also noted they lacked confidence in using PPE and following procedures. Basic tasks took longer and the facility generated significantly more waste.
Coordination with infection control
Although the emergency management department will likely take care of ordering and warehousing materials, infection control representatives should have input in the process. Take multiple factors into consideration, including:
The size of your staff
The surrounding population
The number of other medical facilities around you
What protective equipment frontline staff members use most
What types of PPE are imperative in protecting employees and patients
"Our infectious disease physician is involved when we do the ordering," says Huser. "We aren't just running around in a vacuum, willy-nilly."
Evan Sweeney is an editorial assistant who writes Briefings on Infection Control. He may be reached at esweeney@hcpro.com.
At Heritage Valley Health System in Beaver, PA, patient flow was a major concern, as it has been for many facilities nationwide.
The facility was well aware of the long process patients had to go through to be seen by a physician. In 2006, it implemented electronic kiosks along with a Care Card to help the registration process move more efficiently and maintain constant patient flow.
"Modeled in part on successful implementations in both the airline and hospitality industries, the board and senior management of Heritage Valley developed a strategic plan for enabling and promoting greater consumer participation in the healthcare process through various self-service initiatives," says Robert Swaskoski, director of enterprise resource systems at HVHS.
The Care Card, a plastic ID card that comes in two sizes, one to put in your wallet and the other to snap on a keychain, uses a bar code with a unique identifying number that assists in patient identification at the initial point of registration. The card also functions as a portal that patients use to access their personal care records for HVHS.
Upon scanning the Care Card at a kiosk, the patient is reminded of any tests or exams scheduled for the day. Also, the patient can give any required information at the kiosk.
Goals for the system
HVHS designed the system to address a major patient complaint: the often mind-numbingly long wait times.
"The primary goal of the kiosk was to improve the patient experience by streamlining the administrative processes so that redundant tasks were eliminated and wait times were reduced, thus improving the total time required to provide healthcare services," says Swaskoski.
Prior to the implementation of the Care Card and kiosks, the average patient wait time was 37 minutes. The time was measured from the point patients entered the door to when their lab results were completed.
"The patients had to wait to see a registrar, complete the registration interview process, then wait again to receive their service," says Swaskoski.
Since the Care Card and kiosks were introduced in 2006, HVHS reduced the average wait time to 25 minutes.
"The kiosk check-in averages less than two minutes, and many patients can proceed directly to their place of service as soon as they are finished. The activity monitor that supports the kiosk further improves the process by providing the clinical staff with a real-time view of all patients that are waiting for services and who is next in the queue," says Swaskoski.
The wait time does not include lab test result times, but HVHS is in the process of developing integration between systems so that test results can be directly delivered and available to the patient online, Swaskoski explains.
In addition to cutting down wait time, the Care Card and kiosks have also given staff members more time to focus on patients instead of registration and saved HVHS an average of $1,400 per day, simply by eliminating paperwork and reducing labor costs.
The process also provides a better, more accurate way to gather information and improve the quality of data. HVHS has placed 40 kiosks at six outpatient locations, with plans to expand into the EDs of its two facilities?Heritage Valley Beaver and Heritage Valley Sewickley?as well as physician offices and other outpatient satellite locations, says Swaskoski.
Patients were accepting of the new process because many of them were familiar with the idea of self-service solutions and using kiosks, he says.
Additionally, having fully trained and knowledgeable staff members to help with this new system increased patient acceptance.
"The success of our self-service initiatives and the benefits for both our patients and staff is the result of much more that just the installation of kiosks," says Swaskoski. "Having a clearly defined mission and being encouraged by the board and senior management to make changes, take chances, and learn from our mistakes is absolutely essential to creating solutions, which will improve the delivery of healthcare."
The nation's largest insurers, hospitals, and medical groups have hired more than 350 former government staff members and retired members of Congress in hopes of influencing their old bosses and colleagues, according to an analysis of lobbying disclosures and other records. The tactic is so widespread that three of every four major healthcare firms have at least one former insider on their lobbying payrolls, according to the analysis by the Washington Post.
In the next month, Congress will attempt the daunting feat of turning half-written proposals into healthcare reform legislation that can pass the House and the Senate before the August recess. Who would benefit from expanded coverage, who would pay for it, and how extensively the insurance and healthcare systems would be restructured were a few of the big questions left unresolved when House and Senate negotiators took a break for the Fourth of July recess. In the Senate, Democratic leaders face the additional tasks of merging vastly different proposals from two committees and foiling efforts to shrink or derail the bill as it advances on the floor.
When Congress decides how to pay for President Obama's healthcare initiative, some of his strongest political bastions may be footing a heavy bill. Some of the "bluest" states that propelled Obama into the White House are among those most likely to pay more in taxes to fund expanded health insurance coverage and make other changes to the system, analysts say. People in states such as Illinois, New Hampshire, Massachusetts, Connecticut, and New York have a higher share of wealthier taxpayers and residents who get generous healthcare plans through work—and both sets of people may be tapped to raise money for the healthcare overhaul.
St. James Hospital and Health Centers is moving most elective surgical procedures from its Olympia Fields, IL, campus to its Chicago Heights facility as it consolidates some services to improve efficiency. The recession that began in December 2007 has helped force hospitals such as St. James to rethink the types and number of services they can offer. Now the political landscape could permanently change the way many facilities do business, as hospitals brace for huge cuts in federal health spending proposed by President Barack Obama and Congress to fund healthcare for the uninsured.
The question of whether the government should get in the health insurance business will be debated fiercely in coming months as President Obama and some Democratic lawmakers push for the creation of a government-run plan to compete with private insurance companies. But the federal government is already in the health insurance business, providing coverage to more than 45 million elderly and disabled people through Medicare. And Medicare's record offers insights into the benefits and pitfalls of public healthcare.
As President Barack Obama pushes to overhaul the American healthcare system, the role of government is at the heart of the debate. In Europe, free, state-run healthcare is a given, but the system is far from perfect. In Britain, France, Switzerland and elsewhere, public health systems have become political punching bags for opposition parties, costs have skyrocketed and in some cases, patients have needlessly suffered and died.
