The feud between two former CEOs of Atlanta-based Grady Memorial Hospital continued as one CEO filed court papers denying the other's assertion that he said she was a sexually available woman. The conflict between the two CEOs, Otis Story and Pamela Stephenson, goes back to his tenure at CEO in 2007 and his departure in early 2008. Stephenson was the head of the Grady board that fired him, and the board appointed her to replace him at the helm of the hospital.
David Stark, president of Advocate Lutheran General Hospital in Park Ridge, IL, announced his resignation. Stark will return to Iowa where he has accepted a job as president of Blank Children's Hospital in Des Moines. Stark joined Advocate in February from Iowa Health, Iowa's largest hospital operator.
Pharmaceutical companies are barred by the Food and Drug Administration from promoting unapproved drug uses, but they are using employees called "medical science liaisons," who are often physicians and pharmacists, as a legal way to discuss those uses. Medical science liaisons, who are considered medical rather than sales staff, have greater freedom than salespeople as they visit doctors offices to discuss the science behind a medicine, including unapproved uses.
New York Times columnist Pauline M. Chen, MD, interviews Francois de Brantes, a nationally known advocate of healthcare quality, about Brantes' proposal for a new healthcare reimbursement model that comes with a warranty. The model, called Prometheus Payment, first offers set fees to providers that cover all recommended services, treatments, and procedures for specific conditions but are also risk-adjusted for patients who may be older or frail. The warranty is based on the costs incurred by avoidable complications.
Senate Finance Committee Chairman Max Baucus, D-MT, said today he is "even more confident" that lawmakers can shape a health reform package that would cost below $1 trillion in a plan that could become law by the end of the year.
"We are much closer on the scores for a healthcare reform package than we were at this point last week," Baucus said in a statement.
"We have options the Congressional Budget Office tells us would cost under $1 trillion and are fully paid for."
He added, "We will not put out a mark until we are sure we have it right."
The new proposal will have lower costs and provide quality, affordable coverage for all Americans, his statement said.
Previous estimates from the CBO found that an earlier health reform proposal would be far more expensive, and would take money away from other government health payments. That created an erosion of support and more skepticism as to whether health reform would pass this year.
However, Baucus is confident with today's announcement.
It is unclear how the cost reductions from previous estimates would be achieved, but some said that increasing taxes on employers and employees for health benefits is still on the table.
Another measure would be one that would limit the ability of taxpayers to deduct healthcare expenses over a certain amount of adjusted gross income.
Hospitals are also being asked to accept a number of reductions in reimbursement payments from government payers.
Earlier this month, the 185-bed Doctors Community Hospital, located outside of Washington, DC, in suburban Prince George's County, MD, was fined by state health regulators who said the hospital failed to notify them that a patient had died and that at least seven others suffered serious injuries last year because of medical staff mistakes.
The fine was stiff: $95,000. However, the state officials agreed to reduce the penalty to $30,000, with the remaining $65,000 to be used to develop a patient safety program. Administrators at the hospital have subsequently acknowledged their failure to comply with the law and called the state's action a wake up call to examine patient safety procedures at their hospital, according to an article in the Washington Post.
Unfortunately, this hospital may not be alone in the reporting—or rather non-reporting—department. According to the Agency for Healthcare Research and Quality's Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report, this may be a common occurrence. In its survey for the 2009 report of 622 hospitals with 196,462 respondents, AHRQ found several areas that hospitals could consider in improving their patient safety efforts:
Number of events reported. On average, most of the respondents within hospitals (52%) reported no adverse events in their hospitals in the past 12 months. It is likely that events were being underreported, AHRQ said. Event reporting was identified as an area for an improvement in most hospitals because potential safety problems may not be recognized or identified—and therefore not addressed.
Teamwork within units. This is the extent to which staff support each other, treat each other with respect, and work together as a team. It also was the area that had the highest positive responses (79%), which indicates it is a strength for most hospitals, the report noted. In addition, 86% agreed with the statement that when a lot of work needs to be done, everyone works together as a team.
Nonpunitive response to errors. This is an area with the most potential for improvement, the report noted. About 35% of those surveyed strongly disagreed or disagreed with this statement: "Staff worry that mistakes they make are kept in a personnel file."
Handoffs and transitions. This area also created some concerns, according to AHRQ. Only 41% disagreed or strongly disagreed with the statement that things fall between the cracks when patients are transferred.
According to AHRQ, the survey results are not really the endpoints, but the beginnings of starting a patient safety dialogue. Often the perceived failure of surveys to create lasting change is due to faulty culture of safety or nonexistent action planning. To move to a patient safety culture, AHRQ suggests these steps:
Understand the survey results.
Communicate and discuss the survey results.
Develop focused action plans.
Communicate action plans and deliverables.
Implement action plans.
Track progress and evaluate impact.
Share what works.
It may be a simple formula, but it could help provide a wake-up call to avoid a more punishing—and public—result down the line.
More than 60% of 300 business leaders at companies providing health insurance to their employees say the employer-based health insurance model is unsustainable in the long run, and more than one-third of them support a single-payer health plan, according to a new Zogby International poll.
"When over 60% of respondents believe the employer-based system is not sustainable, that is a clear signal that the time for reform is now," said Charles Kolb, president of the nonprofit, nonpartisan Committee for Economic Development, an organization of more than 200 business leaders and university presidents, which sponsored the poll. "This poll reveals that business leaders are open to comprehensive healthcare reforms that move away from employer-based coverage.
The survey tested support for several healthcare reform proposals and found that:
60.3% support a market-based system of competing plans, where the government organizes a menu of private insurance plans from which each individual may choose.
54% of business leaders support an independent Federal Health Board modeled on the Federal Reserve Board.
36% support a "single-payer" system.
45.3% support an individual market with subsidies for those with low incomes.
43.3% support an employer-based system, with a public option where firms are required to provide coverage or pay into a fund that would subsidize insurance for those who do not receive it at work. Meanwhile, 50.3% oppose this option.
Those of you who plan to move patients into exit corridors when routine ED overcrowding occurs may want to reconsider that policy given what a Joint Commission official said about the matter.
Patients on gurneys and chairs cannot be parked in egress corridors because of Life Safety Code® requirements for minimum clear widths, said George Mills, FASHE, CEM, CHFM, senior engineer at The Joint Commission.
Even if state regulators order healthcare facilities to get patients out of EDs and instead hold them in inpatient unit corridors, The Joint Commission doesn't believe this is the best approach, Mills said during a recent Joint Commission Resources audio conference.
Instead, such a situation should prompt facility managers and ED directors to review ED traffic flow and come up with better ways to manage overcrowding, he said.
An exception to this stance is a disaster-related influx of patients to a healthcare facility, during which corridor treatment of patients may be the only way to deal with a sudden surge of victims.
An exception: Disaster influxes
The Joint Commission's position has wider backing. The Healthcare Interpretations Task Force—an influential group of authorities that reviews National Fire Protection Association (NFPA) provisions for medical settings—developed an informal policy on the matter that frowns upon staging patients in egress corridors.
The task force's decisions aren't formal NFPA interpretations and don't change any the language of standards or codes. However, the task force's members agree to abide by the group's decisions to the extent practical.
An important point: The task force indicated the policy doesn't apply to ED surges caused by disasters that resulted in a large influx of victims to a facility.
The thinking is that such events are hard to fully plan for and the immediate need of medical services may temporarily trump exit corridor requirements in the Life Safety Code.
Hospital moves with state approval
The Joint Commission's stance comes as a surprise to Dennis Irish, spokesperson for Saint Vincent Hospital in Worcester, MA, especially given that the Massachusetts Department of Health and the state fire marshal have communicated about how patient boarding in hallways can work within fire safety requirements. The Department of Health ruled in January 2009 that hospitals in Massachusetts can't divert ambulances to other healthcare facilities to avoid ED overcrowding.
Saint Vincent's policy is to put boarded patients in wheeled chairs—not gurneys—in the hallways on rare occasions when the ED is in danger of being overpopulated, Irish said.
"It's a last resort," he added.
In a letter to local fire chiefs posted online, the Massachusetts fire marshal highlighted the Department of Health's new overcrowding policy. The letter further asked chiefs to work closely with hospitals in their communities to understand healthcare egress strategies in the event that patients are boarded in corridors.
A hospital's IT project list is most likely an exponential one: Convert to an EHR, transition to HIPAA 5010, coordinate vendor and health plan testing, train staff members on new technology, prove meaningful use, and qualify for incentive payments under the American Recovery and Reinvestment Act. It's enough to make anyone's head spin.
"Institutions are being forced to downsize and limit their scope in today's economy. Never has so much needed to be done with so few resources," says Dan Rode, MBA, CHPS, FHFMA, vice president of policy and government relations for the American Health Information Management Association in Washington, DC.
Deadline is January 2012
The transition to HIPAA 5010 is perhaps the most pressing issue because its compliance deadline is little more than two years away. Providers must be ready to submit claims electronically using the upgraded HIPAA standards by January 1, 2012—nearly one year prior to the October 1, 2013 ICD-10 deadline.
CMS recently held its first national provider education call about HIPAA Version 5010, during which it provided an overview of the updated national code standard for billing software and answered several questions from providers, vendors, and other health information management and health information technology professionals.
The X12 Version 5010 and the National Council for Prescription Drug Programs Version D.0 standards will incorporate more than 500 change requests, resolve ambiguities in situational rules, and provide more consistency across transactions, said Kyle Miller, health insurance specialist in the Office of E-Health Standards Services of CMS, during the call.
New data element requirements
In some cases, version 5010 will also include new data element requirements, said Chris Stahlecker, the director of the Division of Medicare Billing Procedures for CMS, during the call. "Everyone should realize that the software used today to produce the EDI transactions must be modified to exchange the new formats," she added. "In addition, you may discover that your business processes may need to be changed."
Medicare has performed a comparison of the current and new formats that hospitals can use to begin performing a gap analysis and evaluate the impact on routine operations.
Medicare Administrative Contractors must be ready to use 5010 by January 1, 2011, giving providers one full year to coordinate testing efforts, Stahlecker said.
The Medicare fee-for-service implementation of 5010 will include the following:
Improved claims receipt, control, and balancing procedures
Increased consistency of claims editing and error handling
Improved efficiency for returning claims needing correction earlier in the process
Improved assignment of claim numbers closer to the time of receipt
Increased field size
The Medicare implementation will result in an increased field size for ICD-10 codes from five bytes to seven bytes. It will also add a one-digit version indicator to the ICD code to indicate version nine versus 10. Finally, it increases the number of diagnosis codes allowed on a claim from eight to 12.
Each MAC will be required to undergo a certification process using self-developed criteria no later than November 31, 2010 to accommodate the 2011 compliance deadline.
"Although we have multiple MACs with individual systems, we want each one to perform as if it were a virtual single system," Stahlecker said. "No matter which MAC you are exchanging transactions with, you should experience very similar processing results."
In addition, CMS will post on each MAC Web site a list of vendors who have completed their testing for the 5010 format.
"Contact your system vendors right away," Stahlecker said. Ask specifically about whether your licensing agreement includes regulatory updates, she added. "If it does, you may have a shorter path toward your implementation, but if it does not, you may have a long procurement path to follow."
CMS said providers should also inquire whether any potential upgrades include acknowledgement transactions 277CA and 999 as well as a "readable" error report produced from those transactions.
The 2008 Report to the Secretary: Rural Health and Human Services Issues, published by the National Advisory Committee on Rural Health and Human Services, identified several factors that contribute to continued rural work force shortages, including high caseloads, long hours on call, isolation from colleagues, lack of easily accessible continuing education and professional enrichment opportunities, limited professional opportunities for spouses, and heavy school debt loads.
The inability to offer a competitive compensation package, the lack of adequate housing, and poor-quality schools are other factors that often make it difficult to recruit physicians to rural communities.
One strategy rural hospitals and communities can use to position themselves favorably is to emphasize their strengths to counterbalance their weaknesses. In other words, rural hospitals should trumpet as many of the following characteristics as they can about their communities:
Successful group practices to join
Attractive compensation levels, when lower cost of living is accounted for
Favorable call arrangements
A hospital that values strong hospital-physician relationships
Local cultural and recreational opportunities
A stable economy, affordable housing, or a good education system
A second strategy is to establish ties with a medical school that has a history of training numerous physicians who practice in rural areas after graduation. Physicians who participate in rural rotations during medical school and residency training are more likely to practice in rural settings, so a hospital or health system that provides these educational opportunities will increase its chances of recruiting young physicians directly out of training programs.
A third strategy is to make optimal use of the multiple government programs that help rural communities recruit physicians. The three types of recruitment incentives include educational scholarships, with subsequent service paybacks; loan repayment for service in designated shortage areas; and J-1 Visa waivers for international medical graduates.
Rural areas have a significant percentage of National Health Service Corps placements. Community health centers located in rural areas are viewed as desirable practice opportunities during training. The J-1 Visa allows foreign citizens to enter the United States for graduate medical education and/or residency training programs.
Foreign physicians on J-1 Visa waivers who commit to practicing in a health professional shortage area (HPSA) or medically underserved area (MUA) for a three-year period are allowed to remain in the United States for three years after expiration of their visas. Because many HPSAs and MUAs are in rural areas, international medical graduates with J-1 waivers are an important source of physicians for rural communities.
