Tracer methodology, used by The Joint Commission since 2004, has increased the focus on the patient care process at the point of care.
"During many surveys, the frontline staff nurse becomes one of the most critical players in not only the tracer process but in the survey itself," says Jodi Eisenberg, MHA, CPMSM, CPHQ, CSHA, program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago. Eisenberg is a columnist and advisor to Briefings on The Joint Commission. "To me, that makes sense. Who spends the most time with our patients? The frontline staff nurse."
This can be a major advantage in that the surveyors are tracing the actual services and care that patients receive. The surveyors have an opportunity to observe care in various locations depending on the complexity of the patients, their length of stay, and the services they received.
Tracer methodology allows surveyors to determine whether there is consistent provision of appropriate and safe access to care, treatment, and services. By viewing care across the organization, it allows the surveyors to validate consistency, safety, and uniform performance of care, treatment, and services. Last, the tracer process provides a view of communication throughout the continuum of care and at discharge and/or transfer to another level of care, whether that is to home or to another type of facility.
"We all have access to some traditional tracer tools, which map out the elements of performance that we find in the standards," says Eisenberg. "The focus of these tools is on general admission, assessment, treatment, reassessment, documentation, education, staff competency, and other areas."
Tracers can be built around the priority focus areas. Clinical service groups can also be targeted as those highlight the types and categories of patients.
Some universal tracer tips for those running the tracers are:
Involve as many people as possible
"Act the part. Be the surveyor."
Ask staff to show you data, policies, and/or procedures
Focus on staff members and not management
Ask open-ended questions
Teach as you go
Hold staff members and management accountable–but don't forget to reward and acknowledge good compliance
An innate challenge to pandemic planning is tracking supply inventories during a response.
On June 15, The Boston Globe reported that in some cases, hospitals ran into obstacles obtaining necessary supplies to combat early H1N1 cases, such as N95-type respirators and antiviral medications.
Medical center purchasing departments, perhaps worried about the prospects of a long-term H1N1 outbreak, tried to stock up on supplies, which occasionally led to competition among hospitals and even within hospitals to get the orders in first.
"I definitely would not use the word 'hoarding,' but there was aggressive ordering of supplies early on in the outbreak and that caused uneven distribution," Paul Biddinger, MD, told the Globe. Biddinger is associate director of the Harvard School of Public Health Center for Public Health Preparedness in Boston.
Part of the problem stems from the fact there isn't a proven metric to determine how many extra supplies a hospital will need during a pandemic or other emergency. An unscientific approach may help, though, said Marge McFarlane, PhD, CHSP, MS (Risk Control), MS (ENPH), MT(ASPC), founder of Superior Performance Consulting, LLC, in Eau Claire, WI. She spoke recently at HCPro's Hospital Safety Center Symposium in Las Vegas.
McFarlane suggested taking the following approach:
Determine your hospital's current census
Figure out the necessary supplies to handle that census
Consider those same needs if the census suddenly doubled
The Joint Commission's emergency management standards mandate that hospitals document and annually evaluate inventories of resources and assets that might be needed during a disaster. These resources include, but aren't limited to, the following:
Personal protective equipment (e.g., respirators)
Water
Fuel
Medical and surgical materials
Pharmaceuticals
For the past year, The Joint Commission has been warning accredited hospitals about limited access to supplies, particularly utilities, during emergency responses. George Mills, FASHE, CEM, CHFM, senior engineer at the commission, often notes his frustration at the lack of realistic utility contingency plans at healthcare facilities.
Memorandums of understanding (MOUs) between hospitals and vendors lay the groundwork for supply and utility back-ups during emergency response. But MOUs may be insufficient when a real disaster strikes, particularly if several hospitals in a region rely on the same vendor for help.
At the American Society for Healthcare Engineering's 2008 conference in National Harbor, MD, Mills suggested neighboring hospitals get together, compare their MOUs, and collectively make a series of calls to a vendor to test the agreements simultaneously.
Mills told an anecdote about a city water plant that went out of service: Several hospitals in the area had MOUs with a sole vendor to receive 10,000-gallon water bladders as a back-up. At 2 a.m. the next day, a manager at one of the hospitals called the vendor about the bladder and had the item delivered at 6 a.m. The other hospitals called later asking for their bladders, only to find the only available bladder had already gone out, Mills said.
There is much talk these days among hospital emergency planners about the need to engage community partners when developing hospital response procedures. Typically, these partners include police and fire departments and local health departments.
But hospitals should also put vendors on the list of community entities to plan with, particularly when it comes to supply chains. Talking ahead of time with vendors may help eliminate bottle-necks in the demand for supplies when an emergency or H1N1 outbreak occurs.
I've been at the Healthcare Financial Management Association annual meeting in Seattle all week, so healthcare's been on the brain even more than usual. In fact, I wasn't even able to escape it in family e-mails this week. That's because my dad got his EOB statements from his recent cataract surgeries performed on both eyes.
Incidentally, the surgery went great. My 73-year-old father, who still runs about 15 miles a week, is now able to see without glasses—something he hasn't been able to do since he was about 14 years old. He also has figured out that in bright sunlight, most people—now including him—need sunglasses, something his cataracts kept him from noticing much in the recent past. So he's more than pleased with his eyesight, thank you very much. What he's not so pleased about was the cost of the care he received. His anesthesiologist bill for the surgery was just less than $1,000 for a 10-minute operation.
So his question to me was:
"Am I am paying for all the free healthcare given to others or what?"
On the surface, it's a simple question. But most of you know how complicated a full explanation really is. So as I always do when family members ask me to explain something about healthcare, I took a stab at answering.
"In short, yes, you are." I said. "But not as much as I am" (because he's on Medicare).
"Hospitals subsidize free or uncompensated care by making it up with commercial insurance plans, one of which covers all my healthcare. That's known as cross-subsidization. Most of yours is covered by Medicare, which doesn't pay enough to subsidize free care. Of course, what I'm saying is a blunt way to answer a question that's very nuanced, but essentially true."
So what's the point of all this? You've probably given a similar explanation to friends and family as the one I gave my dad.
Now, my father is not the biggest Obama fan. He agrees with Democrats about as often as often as my seven-month-old twins recite the Gettysburg Address, which is to say, almost never. I am skeptical not only of Democrats, but Republicans, independents, et al. At best, most of them are only interested in getting re-elected. At worst, they're interested in lining their own pockets. Either way, they're out for their own narrow self-interest.
But I give the president high marks for trying to tackle some of the seemingly intractable systemic problems that affect healthcare today—chief of which is its unaffordability—in the short-term for the uninsured—in the long-term for all of us. Not only is he working to solve a very pressing problem from the bully pulpit, but he even managed to make it through a speech at the American Medical Association's annual meeting this week.
Granted, healthcare reform still isn't very specific. There's still no bill, and lots of options are still on the table. But that's leadership, folks. Being frank and open with constituencies about potential solutions to difficult problems—not particularly caring where good ideas come from.
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Despite the talk of healthcare reform and a deep recession that has brought layoffs, salary freezes, and wage cuts, medical costs in the United States are expected to grow by 9% in 2010. The increase continues a disturbing trend that has health insurance premiums growing four times faster than wages during the past five years, and the move to implement healthcare reform is not expected to affect costs until at least 2011, PriceWaterhouseCoopers Health Research Institute reports.
About the only solace that can be drawn from the report—Behind the Numbers Medical Cost Trends for 2010—is that the 9% cost growth in 2010 is at a pace slightly slower than in 2008 and 2009.
The report paints a grim picture of American workers, those lucky enough to have jobs, who are trapped between sharply rising healthcare costs and stagnant or shrinking salaries.
The recession is having a mixed effect on medical costs. On the one hand, the report notes that high-deductable health plans will see lower use in 2010 because the record number of workers now in those plans won’t have the money to pay for procedures, a trend that is expected to slow the rate of medical cost increases.
On the other hand, many workers still fortunate enough to have jobs, but who fear losing them, may be using more services while they still have health insurance. Health plan executives interviewed indicated they are not seeing a reduction in overall utilization.
The report also found that:
The recession and the prospect of health reform will help temper medical costs, impacting the pricing
As the recession pounded corporate profits in early 2009, employers surveyed say they were ready to push more of their health insurance costs to their workers in 2010 while expecting more responsibility from workers for managing their personal health
Although health reform will have a major impact on the industry, its effect on medical costs likely will not be felt until 2011 or later.
More than two-thirds of employers expect to expand wellness and disease management programs, although few are convinced that they are very effective at mitigating healthcare costs.
42% of employers surveyed say they would increase employee contributions, up from 38% in 2008, and 41% say they expect to increase medical cost sharing through plan design changes.
Increased cost sharing could squeeze workers, many of whom took wage cuts in 2009 because of the recession. In the last five years, health insurance premiums have increased four times faster than wages, a trend that is expected to continue in 2009 and 2010. If employers follow through on plans for increased cost sharing, the affordability gap could grow even larger.
Although health reform will have a major impact on the industry, its effect on medical costs likely will not be felt until 2011 or later. However, the prospect of health reform may have a dampening effect on overall healthcare price increases as it did during the Clinton health reform years.
New Jersey state mental hospitals have laid off 16 doctors in order to fix budget gaps, according to the state Department of Human Services.
Typically, hospitals do not have the authority to lay off medical staff members because most are not directly employed by the hospital. However, some practitioners, such as hospitalists and contracted physicians, are direct hospital employees.
Does this mean MD layoffs can become a common occurrence at private hospitals as well?
Only time will tell how common the occurrence becomes, but some private hospitals have already made medical staff cutbacks.
"It can happen anywhere and unfortunately there's a perfect storm because you've got decreased Medicare/Medicaid reimbursement, you've got increasing bad debt, you've got the economic melt down of many hospital's investments," says Jonathan H. Burroughs, MD, MBA, FACPE, CMSL, senior consultant at The Greeley Company, a division of HCPro, Inc., based in Marblehead, MA. "Almost every hospital in the nation is facing budget shortfalls and budget cuts and one of the expenses on the ledger is physicians' compensation."
The American Medical Association and American Hospital Association do not keep statistics on how many doctors have been laid off for financial reasons. However, the AHA does track how many hospitals have cut staff positions across the board. Since September 2008, 48% of hospitals have reduced staff in response to economic concerns, according to a March 2009 report.
There are several types of doctors that hospitals have the authority to lay off for financial reasons. These include state employees, contracted practitioners, hospitalists, and practitioners who are dismissed on the basis of economic credentialing.
Contracted employees are the easiest group to lay off. "Many of their contracts have what are called clean sweep arrangements, which means when the contract is terminated all of their medical staff privileges and rights are terminated as well," Burroughs says.
Practitioners can protect themselves by structuring their contracts so that if the hospital terminates their contract, their status is restored to medical staff privilege rights.
Hospitalists can also be easily laid off because they are direct employees of the hospital.
Economic credentialing is more challenging for a hospital to implement. Only some states have laws allowing economic credentialing, which is the practice of denying clinical privileges because of financial rather than competency concerns. Hospitals can dismiss a practitioner for economic credentialing reasons at any time; they do not need to wait until the end of a reappointment cycle to act.
Burroughs recommends that hospital CEOs considering laying off doctors to fix budget gaps should first consult with medical staff leaders who can speak to quality of care issues. "I think the wise CEO will consult with those physicians and make the decision as collaboratively as possible," he says.
Emily Berry is an associate editor for Briefings on Credentialing and Credentialing Resource Center Connection, and manages the Credentialing Resource Center. You can reach her at eberry@hcpro.com.
Health insurers are paying physicians 5% faster and denying 9% fewer medical claims than last year, but some payers still have a ways to go, most notably state Medicaid programs, according to athenahealth's fourth annual PayerView Rankings.
The Internet-based provider of business services to physician practices evaluated 172 national, regional, and government payers in 40 states, which was the largest data set to date. The company used performance data from more than 18,000 medical providers and $7 billion in charges billed in 2008.
Athenahealth found that many payers are collaborating more with physicians to automate various claims and billing work, while reducing administrative costs and streamlining claims processing. That allows providers to focus more on delivery of care. Jeremy Delinsky, vice president of athenaNet Intelligence for athenahealth in Watertown, MA, says health insurers should focus on reducing administrative waste from the healthcare system.
He adds it's up to stakeholders to remove inefficiencies or someone else—such as the federal government through the proposed public insurance option—will.
Through its research, athenahealth found these trouble spots often lead to delayed physician payments:
Health insurers' varied policies and procedures for claims submissions and payment that can cause confusion in physician offices.
Real-time claim adjudication that don't help practices integrate the technology into their workflow, but is really a euphemism for additional work for practices, such as needing to rekey information onto the payer's Web site.
Insufficient resources for providers, including inadequate call center staff, which makes it difficult for offices to research and/or follow claims, leading to misinformation and additional phone calls to resolve the issues; outdated and difficult to find provider manuals and other documentation; and incomplete information that doesn't provide enough insight to help offices learn where they may have made mistakes in the process.
Humana is tops
Humana topped athenahealth's rankings for the second time in four years and garnered the top spot in fewest days in accounts receivable for national payers. Humana edged out Aetna and Cigna, the highest rated national payers in the 2007 and 2006 athenahealth results respectably.
Mark Smithson, vice president of provider process and network operations at Humana in Louisville, KY, points to two reasons for the high marks: real-time claim adjudication and electronic remittance devices. Smithson says many health insurers say they have real-time claim adjudication, but still require physician offices to log onto the payers' sites and rekey in the information. This merely adds work to physicians' offices. Instead, insurers should integrate the claim adjudication process into the physician offices' practice management system, he says.
"We don't change dramatically how they put their charges in," he says. "Not only does it help at the patient collection window; it also speeds up the entire process."
Not that the changes are seamless. Smithson says the health plan and office must work to have the process complement the workflow, but realize the changes will affect workflow. "What this does do is streamline all that so the person is no longer in the back office, but in the front office at the patient window so it does somewhat disrupt their workflow," he says.
For instance, one practice has color-coded Humana patient charts so the office employees know that it has a different workflow than others. What's important is to educate the physicians' offices from the start so they know what changes are needed. "The better the communications upfront the more smooth the whole transition is going to run," he says.
Smithson says Humana's mindset is that it would rather pay pennies to process the claims through streamlined processes and avoid backend phone calls. Smithson says each phone call avoided saves the company $7.
Medicaid is a problem
While many of the national and regional health plans performed well, state Medicaid programs were at the other end of the spectrum. Medicaid had a twice longer days in accounts receivable (DAR) than other groups and denied more than one in every five claims.
The New York Medicaid program ranked worst for DAR and first-pass resolve, which athenahealth suggested was because of:
Complex authorization requirements
Use of proprietary claim forms for paper submission
Lack of acknowledgment from Medicaid-NY for claims submitted
Use of identical remittance codes to indicate both denied and pended claim scenarios
Onerous enrollment processes
These results are quite different from Medicare, which received much higher marks in the rankings. Diving deeper into the findings, athenahealth found that Medicaid managed care programs, which are operated by private insurers, performed much better than state Medicaid programs.
One problem is that states faced with limited budgets often make cuts to Medicaid programs and/or stop paying claims, he says.
"That is essentially like taking an interest-free loan on the backs of medical providers. There has to be a better way to fund the system than to have providers essentially treat patients for free upward of 90 days. That just doesn't feel like the states have responsibly managed their budgets if that's happening. You can understand why the provider wouldn't want to participate in the program," says Delinsky.
Delinsky says athenahealth's rankings look at administrative ease and efficiency, but the company would like to expand its program to include other areas to make them more meaningful for providers. "I think you can probably make some correlation about administration efficiency if you had more data publicly about these companies, but it doesn't get into comparative payments yet. That is something we're likely to do in coming years," he says.
President Obama's hopes for quick action on comprehensive healthcare reform ran headlong into the realities of Congress, as lawmakers searching for the money to pay for a broad expansion of coverage discovered that it wasn't easy to find and descended into bickering. A set of unexpectedly high cost estimates forced one key committee to delay action on its bill, probably until after the July 4 recess.
A draft proposal in the Senate to overhaul the nation's healthcare system would require most people to buy health insurance, authorize an expansion of Medicaid coveragem and create consumer-owned cooperative plans. The document addressed none of the funding questions that have consumed House and Senate negotiators, but it included an array of coverage provisions that were drastically scaled back from earlier versions as lawmakers seek to shrink the bill's overall cost. The proposal, for instance, would reduce the pool of middle-class beneficiaries eligible for a new tax credit meant to make insurance more affordable.
The high cost of securing health insurance for all Americans has Congressional Democrats scrambling to scale back their proposals or find ways to trim tens of billions of dollars a year from existing health programs. According to slides presented at a closed-door meeting, members of the Senate Finance Committee are debating several new ideas, including "an automatic mechanism" to reduce the growth of Medicare under an expedited procedure like the one used to close military bases.
Five months after President Obama's inauguration, healthcare dominates the domestic agenda. Any package that emerges could bring sweeping changes, requiring that everyone be insured, creating a government health plan to compete with commercial carriers, and perhaps taxing employer-provided health benefits. But students of history realize we are only now entering the riskiest phase, when real details begin to generate real opposition, according to this New York Times article.
