A review at two Canadian teaching hospitals reveals that in a two-month period, 14% of all hospital pages were sent to the wrong physician—a resident who was scheduled to be off-duty or out of the hospital—and 47% of those were urgent messages. That's about 2,000 misdirected pages per year per hospital that require an immediate response, but don't get one, the study found.
Increasingly, doctors are looking beyond conventional care to treat their patients with alternative approaches such as herbs, acupuncture, and yoga. Studies also show that the number of Americans willing to try alternative treatments continues to increase. A 2007 survey by the federal government found that more than one-third of adults and nearly 12% of children in the United States used alternative therapies. And health insurers are beginning to recognize and pay for some alternative therapies, including acupuncture and herbal remedies, although Medicaid and Medicare do not cover them.
Congress may find it difficult to finance universal coverage unless it limits to some extent the exclusion of employers' health insurance payments from employees' income and payroll taxes, according to a new study from the Center on Budget and Policy Priorities in Washington.
"There are a huge number of ways to raise additional revenues," said Paul Van de Water, a senior fellow at the center, who authored the report. "At least in theory, one could pay for health reform without limiting the employer exclusion. But, when we go through the individual options one by one and think about all of the objections that are raised to them, we think as a practical matter that it may be very hard to pay for health reform without doing something to limit the employer exclusion."
The issue, in various forms, has been discussed by the Senate Finance Committee as a way to pay for coverage under healthcare reform. So until other alternatives are identified and settled, "we shouldn't rule this or anything else off the table," said Van de Water, who previously served as vice president for health policy at the National Academy of Social Insurance and as deputy assistant director for budget analysis with the Congressional Budget Office.
The current exclusion is poorly designed, which gives a greatest benefit to those with higher incomes, according to the report. The higher exclusion can provide an incentive for employers and individuals to select more generous or costly coverage, which in turn could lead to an increase in healthcare service demand that pushes up prices.
In a way, limiting tax exclusions could push in the direction of greater efficiency in the healthcare system, Van de Water noted. Those with higher benefits might end up seeking more economical plans that use resources more effectively.
"It's not a perfect tool, but clearly we're going to have to do a lot of different things to drive the system to be more efficient. This is one that would run in the right direction," he said.
It's unlikely that Congress will choose to move toward making employer sponsored insurance totally taxable. "That clearly doesn't seem to be in the cards," Van de Water said. Instead, other options could be considered, such as basing limits on household incomes, basing limits based on the value of insurance, or basing limits on both incomes and insurance value.
Any proposal, though, to cap the tax exclusion that is based on insurance value must specify separate limits for each type of coverage, the study said. If the limits fail to reflect the differences in the cost of insurance, the exclusion could end up affecting a greater proportion of those with family coverage than those with individual coverage--or vice versa.
Attention also will be needed to modify tax exclusions for companies whose premiums are high because workers are in an area with higher healthcare spending or have employers who are older or sicker--causing premiums to be higher.
As for acceptance by the White House, it's probably wait and see. The president, during his campaign, said he opposed taxing insurance benefits. "I think our feeling is that at the end of the day, the White House has clearly said that they believe that health reform needs to be paid for," Van de Water said. "Health reform is important, but we also think that equally important it should be done in a way that doesn't add to the deficit."
The administration is likely to reject a health reform plan that is not paid for, "but I don't think they are going to reject something that is paid for in a way that wasn't their first choice," Van de Water said.
Building and maintaining a culture of safety has become a key part of a patient safety program. Since the Institute of Medicine's To Err is Human was published 10 years ago, the healthcare industry has made a concerted effort to focus more energy on creating systems by which patients are kept more safe, and staff members are set up to succeed.
This year's Briefings on Patient Safety Culture of Safety Survey results show that while the overwhelming majority of hospitals are addressing their cultures of safety, there are certain areas to which more attention could be paid in the future.
More than 900 patient safety professionals answered the survey questions, most of whom (84%) worked at hospitals. When asked if they thought their facilities had strong cultures of safety, 41% said yes, and 57% said "We are working toward improving our culture of safety." This is encouraging, although perhaps suggests that healthcare as an industry may not have one "strong" culture of safety definition.
"I think that's a very positive thing, but I think the healthcare industry really needs to be careful of not becoming overconfident and complacent," says Ken Rohde, senior consultant for The Greeley Company, a division of HCPro Inc. "What the healthcare industry considers a strong culture of safety might be actually relatively weak compared to aviation or nuclear power or other high risk industries. If everybody thinks they're getting an A in healthcare, that might only be a C- in the rest of high-risk industries."
Another question on the survey asked respondents to evaluate what has caused (if any) an increase in the attention paid to creating and maintaining a culture of safety. The majority of respondents said that their hospital was motivated by external agencies.
Twenty-five percent said motivation came from increased requirements from accrediting bodies (The Joint Commission) and 34% said motivation came from large patient safety groups (IHI, National Quality Forum). Twenty-seven percent answered "It's just the right thing to do," 4% said a near miss or medical error had caused the facility to pay more attention to culture of safety, 1% listed an increased financial incentive, and 8% gave other reasons.
"We need to make sure we're getting away from being externally driven, because as soon as somebody backs off, the Joint Commission isn't pushing us, then people will slide right back to where they used to be," says Rohde. He also says he hopes that that next time the survey is conducted, more respondents answer with "it's just the right thing to do."
One other point that this question brings up about building a culture of safety is the role that error reporting plays. Though it may not be a bad thing that only 4% of respondents attributed the occurrence of near misses or medical errors to why the culture of safety has been given more attention, it does open up the possibility that many hospitals do not have comprehensive error reporting systems in place.
"A hallmark of a strong safety culture is that it is a reporting culture," says Mary Voutt-Gous, RN, BSN, CCRN, director of patient safety initiatives for Henry Ford Health System in Detroit, MI. "That helps us identify weaknesses and prevent errors. High reliability organizations do that."
Voutt-Goos suggests that facilities step back and evaluate how their error reporting is used. If it's used as a weapon, it's likely that most staff members will not report when an error or near miss has occurred. Although most staff members would answer on a survey "yes, I'd speak up if I committed an error," most staff members can also identify scenarios in which it might be difficult to speak up when asked personally. Leadership actions can precipitate the environment that exists within a hospital.
"There's a disconnect between what they know is right to do, and what they're comfortable doing in specific environments," says Voutt-Goos. It is imperative that managers find out where those weak spots are and focus on building trust between leaders and front-line caregivers. Though staff members usually have patient care at the core of their daily jobs, there's definite concern about their own personal reputation and future at the facility.
"When you speak up, that can be viewed as a troublemaker, and that can impact your career," says Voutt-Goos. She suggests that hospitals make the act of speaking up and reporting errors less personal and create consistent policies about how those types of situations will be handled.
The American College of Emergency Physicians, still stinging over its exclusion from the high-level healthcare reform debate, has launched a letter-writing campaign among its 27,000 members, urging Congress to address emergency patients' needs as they take up the issue this month.
"Nearly 120 million people are treated in our nation's emergency departments annually, and we expect that number to climb with each passing year," says ACEP President Nicholas Jouriles, MD. "People age 65 and older represent the fastest-growing segment of the population and the group whose visits to the emergency department are increasing the fastest. These are also the patients who require the most acute care and are admitted to the hospital from the emergency department most often. This could lead to catastrophic crowding in just a few years."
ACEP has not hidden its disappointment and resentment after emergency physicians were not invited to attend a White House summit on healthcare reform this spring, while other groups, such American Medical Association, the American Hospital Association, and America's Health Insurance Plans, were given front-row seats. In the face of an indifferent White House, ACEP is making an appeal to Congress.
Jouriles says Congress must bolster the nation's safety net system to meet current needs, even as lawmakers consider reforms to the healthcare system that will not play out for many years. He says workforce issues persist across all of medicine, including emergency care, and will likely grow more acute as physicians in the Baby Boomer generation retire. Jouriles points to a Government Accountability Office report released in April that found that patients who need to be seen in less than one minute in the emergency department are now waiting an average of 28 minutes for care.
ACEP has maintained that widespread claims by some members of Congress and in the news media that universal health coverage will ease emergency department crowding are not supported by data. CDC reports that 83% of emergency patients have some type of insurance, and Jouriles says emergency department use in Massachusetts increased following the 2006 enactment of mandatory health insurance for all state residents.
"Even if everyone had primary and preventive care tomorrow, emergencies will continue to be a fact of life," Jouriles says. "Considering how many patients emergency departments treat every year and how many resources they can draw upon in one place, it is remarkably cost-effective," he says. "Emergency care accounts for less than 3% of the nation's $2.1 trillion in healthcare expenditures, but is a priceless public resource."
Lately, I've been hearing different versions of the following caveat from a growing number of healthcare leaders: "Our plan is X,Y, and Z, but of course it could all get wiped out with healthcare reform."
The biggest problem with healthcare reform right now isn't healthcare reform itself. It's the proliferation of talk and political posturing, which causes fear and a hunker-down mentality that is unlikely to pass until we can get some clarity on what the future will bring. By this, I mean at the very least a comprehensive legislative package, which President Barack Obama has requested by Oct. 1.
Healthcare leaders I've spoken to in recent weeks say the economy and the uncertainty of what health reform will mean a year from now is stalling strategic plans like never before and causing many to pull back from committing to any capital projects that aren't vitally necessary. Others say the mood is one where organizations are not looking to enter into new debt for the remainder of the year. Having cash in the bank is a No. 1 priority, and admittedly a good one in any environment.
While we don't know whether we can really believe politicians when they promise meaningful reform, we can't rule out something big happening. Three big questions that need to be answered before many will feel like they can make solid plans are: Will there be universal coverage? Will there be bundled payments and will there be a public health plan? Wary leaders know that a yes to any one of these could potentially send some hospitals into a financial tailspin and eat up available reserves.
In the meantime, just in the last week alone, several big news stories came out regarding healthcare reform moves on Capitol Hill. President Obama met with a couple dozen Senate Democrats and followed up his visit with a letter outlining his support of an insurance mandate for all Americans. And according to some Senate Democrats, he has expressed a willingness to consider a tax on employer health benefits, something he was vehemently opposed to during campaign season. And again, the question is will any of this make it into a final reform package?
For those of you spending 12 hours a days running the business of healthcare, here is what happened on Capitol Hill.
President Obama supports mandate for adults:In a letter to Senate Democrats, President Barack Obama stresses the need for legislation that includes health insurance coverage for every American. The president didn't provide a broad outline on how to cover the close to $1.5 trillion this could cost, but said he would "set aside $635 billion in a health reserve fund as a down payment on reform."
Senators to have a bipartisan bill this summer:Senate Republicans are grumbling after President Obama sent a letter to Senate Democratic leaders saying he supports "moving towards a principle of shared responsibility—making every American responsible for having health insurance coverage, and asking that employers share in the cost." Some senate Republicans say the letter will make it difficult to gain bipartisan support for a healthcare reform package. Nonetheless, Sen. Max Baucus (D-MT), chairman of the Senate Finance Committee, and Sen. Charles Grassley (R-IA), the ranking minority member of the Senate Finance Committee, in a joint statement this week said they will have a bill that is close to universal coverage this summer.
Employer tax is on the table: When he was campaigning for president, Barack Obama came out guns-blazing against Sen. John McCain (R-AZ) for proposing a tax on employer health benefits. Now, it looks as if it wasn't such a bad idea after all. According to this Washington Post article, taxing employer health benefits above $14,000 could yield $35 billion a year and is something President Obama will now consider.
Leftist groups back public health plan: Organizations such as MoveOn.org and the AFL-CIO converged on Washington this week in support of specific reform measures such as a government-backed public health plan.
Healthcare groups propose $2 trillion in savings: Leaders from six healthcare groups, including the American Medical Association and the American Hospital Association, spoke at the White House last month promising to find ways to reduce yearly healthcare spending by 1.5%. They presented their findings this week. In this article by HealthLeaders Senior Editor Janice Simmons, healthcare stakeholders highlight three areas in which the industry can save, including utilization of care ($150 billion to $180 billion), chronic care ($350 billion to $850 billion), and administrative simplification ($500 billion to $700 billion).
Report: Reducing healthcare costs will give significant boost to economy:A report by the Council of Economic Advisers, which reports to President Obama, says slowing growth of healthcare costs 1.5 percentage points a year "will increase real GDP in 2030 by nearly 8%."
Once we move past the rhetoric and onto meaningful legislation, maybe healthcare organizations will have more resolve to get back to the business of planning.
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Harold Pollack, a public health policy researcher at the University of Chicago School of Social Service Administration, says nonprofit hospitals should be very nervous about the status of the approximately $6 billion in annual tax benefits they get each year. As Congress looks for a way to pay for healthcare reform, nonprofits need to be prepared to detail the extent of their charity care.
Roger A. Oxendale, CEO of Children's Hospital and president of the Children's Hospital of Pittsburgh Foundation, will resign from both positions at year's end. Oxendale, 55, oversaw the move to the new 10-acre, $625 million campus in Lawrenceville this spring. Oxendale joined Children's in 1995 as CFO. He became the hospital's CEO and president of its foundation in 2005, four years after the hospital had merged with the University of Pittsburgh Medical Center.
Brockton Hospital Chief Executive Officer Norman Goodman resigned from his post amid a cloud of "inappropriate behavior" allegations. Goodman released a statement on June 6. He had been CEO of Signature Healthcare Brockton since 1990.
Memorial Hospital in Conway, NH, has a new president and CEO. Scott McKinnon, of Phoenixville, PA, will succeed Gary Poquette, who is retiring after 30 years at the hospital. Poquette's last day is June 30. McKinnon starts in mid-July. McKinnon was chosen after a nationwide search. Since 2003, McKinnon has been employed as a vice president at Lankenau Hospital in Pennsylvania.
