In my many years of writing about hospitals and their problems, I know this:
Medical and administrative executives dread nothing more than to hear that their hospital's failure to comply with license requirements came close to causing—or actually did cause— injury or death to a patient. Jeopardy is not the name of a game. It's their biggest nightmare.
The 14 financial penalties levied against 13 California hospitals last month re-opened the wounds those tragic incidents inflicted on the hospitals' reputations and the careers of the individuals involved, not to mention the patients and their families, even though the events happened as much as six to eight months earlier.
Perhaps adding salt to those wounds, California officials have held six press conferences in the last two years to announce the 87 financial penalties so far assessed each of the hospitals where such events occurred. And each time, they have thrown a public spotlight on documents that describe, frequently in explicit detail, the precise sequence of events leading up to the dreaded event.
The wrong-site surgery, the fatal medication error, or the sponge left inside the patient.
The "awake" surgery when the anesthesia delivery equipment went unfixed, the delayed medication order, the subcutaneous medication that was given intravenously, the fatal fall, the patient who suffocated to death in restraints.
Who made the mistake, who forgot protocol, who altered a record, and who said what to whom is all explained right there on a state Web site for the public to easily see.
The $25,000 penalty the state now imposes is hardly comparable to the shame (even though the fines go up this year to $100,000 for repeat offenses). And while rural hospitals have not suffered as much from these reports as have larger hospitals where more complex patient care is routine, the impact can be devastating on the morale of the entire staff and even an entire community.
California officials and consumers argue that the publicity surrounding such events is a strong motivator for health officials to design and implement systemic changes that make it much easier do the task correctly than to make a mistake.
Apparently, there is similar thinking among the members of the Senate Finance Committee. In their report one month ago, one of their many quality improvement proposals was the imposition of federal financial penalties against any hospitals "that have been cited by the Secretary for deficiencies that posed immediate jeopardy to the health or safety of patients."
Similar financial penalties are contemplated for nursing homes in the event a patient is harmed, or in immediate jeopardy of being harmed.
In California, there is an imperative to use the mistakes as an opportunity to learn how to avoid them.
Of the $2.175 million in fines assessed, the state has collected $1.2 million as of Jan. 1 of this year. All of the funds are legally required to be spent for quality improvement research and monitoring, state officials say.
Licensing and certification officials expect the first $300,000 of the money to be released in the next few months, and plans to spend $150,000 of it to hire a consultant who would review and track more than 1,000 adverse events in general acute and psychiatric hospitals that were reported to the state. All but the 87 were not serious enough to merit a finding of immediate jeopardy.
The other $150,000 will be used to bring "a culture change" to chronically challenged nursing homes—facilities that represent a significant share of state investigators' workload.
Already, efforts are underway to alleviate the biggest reasons for adverse events. In the fiscal year ending June 2008, the state investigated 581 instances of stage 3 or 4 pressure ulcers acquired after a patient's admission. There were a reported 165 instances of a foreign object such as a sponge or device unintentionally retained in a patient. And, 33 patients died due to an avoidable fall.
It's unclear whether health reform programs now being proposed at a federal level will result in fines. Although it is now established that the federal government will no longer pay for any follow-up care required as a result of a "never" event, such as surgery on the wrong patient, surgery on the wrong body part, or the wrong procedure.
If there are to be fines, however, perhaps the money can likewise be put to good use at a national level to promote research into the circumstances that lead to such events, as well as solutions for how they can be avoided.
A new report released today confirms what a lot of people would have guessed: 2008 was not a good year for managed care companies.
Even though eight of the nine managed care companies reviewed in the KPMG Healthcare and Pharmaceutical Institute's 2009 Managed Care Industry Report saw declines in net income in 2008, the report projects some improvements in 2009, despite a poor economy and uncertainty about the impact of federal healthcare reforms.
John Fitzgibbon, KPMG's managed care sector leader and the author of the report, tells HealthLeaders Media that the managed care industry hasn't seen tough times like this since the mid-1990s. However, he says there is no cause for alarm. "As a group they are still pretty solidly profitable. It's just that the level of profitability is lower than it was in 2007. For the four preceding years, there was not only solid profitability but increasing profitability. That trend changed in 2008," he says.
His report notes that the bleak economy, rising numbers of uninsured, and rising medical costs, are among the factors that are negatively impacting the managed care industry and which are largely beyond its control. "The recession promises to be long and deep, the number of jobs continues to decline, the financial system is in disarray, and consumer confidence is low," Fitzgibbon says in the report. "Most healthcare companies are finding that their businesses are less recession-resistant than previously thought, and the future is uncertain. Managed care companies are faced with declining enrollment as unemployment increases and a tough pricing environment. This will undoubtedly be a challenging year financially for managed care companies."
There is also anxiety in the managed care industry about the impact of yet-to-be-crafted healthcare reforms being considered by Congress. Many insurers anticipating that the final product will provide some gains and some losses. "Provisions to increase federal funding of existing healthcare programs and to decrease the number of uninsured Americans should have a positive impact on managed care companies," Fitzgibbon writes. "Provisions to reduce Medicare Advantage premiums and establish government sponsored health plans probably would not."
The report found that:
Net income declined for eight of the nine companies analyzed in the report for the year. Income increases for HealthSpring Inc. were mostly attributed to "the loss of low-margin commercial members."
Membership growth slowed in 2008, and several companies ended the year with fewer members than the previous year. "Organic" membership percentage growth will be "in the low single digits" in 2009.
Most managed care companies underestimated the rate of increase for medical costs in 2008. That and tanking investments were identified by Fitzgibbon as primary drivers for financial losses. Premiums went up in 2008 but not at a rate high enough to offset increased medical costs.
Managed care companies expect modest economic improvement in 2009.
Cost of care is expected to increase in by 7% - 8% in 2009.
Administrative costs rose for all nine managed care companies, and in some cases those costs rose faster than revenues. Stock performance for managed care companies in 2008 was "very poor," and "fell along with the rest but fell faster and farther," Fitzgibbon writes. "The Morgan Stanley Healthcare Payor Index fell almost 55% during 2008, compared to a 38% decline for the Standard & Poors 500 stock index. On Dec. 31, 2008, the Morgan Stanley Healthcare Payor Index stood approximately 12% above its level five years earlier." He say that many managed care stocks have "bounced back" in the last few months, but are still well below historic highs.
Despite the bleak times, Fitzgibbon says that industry pricing discipline remains strong, and managed care companies report that the market is "competitive but rational. Competitors are unwilling to sacrifice margin for increased membership."
The nine managed-care companies covered in the report are: Aetna Inc.; AMERIGROUP Corp.; Coventry Health Care, Inc.; Health Net, Inc.; HealthSpring, Inc.; Humana Inc.; Kaiser Foundation Health Plan and Hospitals; UnitedHealth Group Inc.; and WellPoint, Inc. The data used in the report was taken from annual reports, and filings to the SEC and other regulatory agencies, and public sources from 2004 to 2008.
President Barack Obama has signed a $787 billion stimulus bill into law, and expanding healthcare coverage is clearly one of the plan's largest priorities: Approximately $150 billion is dedicated to healthcare expenditures. The Medicaid supplemental funding and $19 billion earmarked to pay up to 65% of COBRA premiums for laid-off workers are the top two biggest expenditures and comprise more than two-thirds of targeted healthcare spending, for example. Below you will find a comprehensive list of news and analysis about this historic event.
Consumer incentives are often thrown around as healthcare panacea. Send out a few gift cards and watch program enrollment increase as members lose weight, quit smoking, and generally improve their health as bad habits are eliminated.
Through our experience running consumer incentive programs, we've found that elements of this are true. As healthcare consumers, we are all complex. We often run into barriers and can't get things done, have trouble making a long-term commitment, and, simply, may not have much interest in our changing behavior.
Whether the consumer is a member of a commercial health plan or a Medicaid program, the incentive isn't a silver bullet. It can't stand alone as the total solution, but it can be an important part of the package.
At least two studies have taken a look at how incentive plans can affect healthcare consumers and their attitudes.
In the AHRQ report, they were particularly interested in how consumer incentives could help health plan members make certain choices, including:
Selecting a high-value provider
Selecting a high-value health plan
Deciding among treatment options
Reducing health risks by seeking preventive care
Reducing health risks by decreasing or eliminating high-risk behavior
Participants–especially those with chronic illnesses–should be the center of attention when it comes to incentives, according to the report. (While they are a small group, they make up a large part of a plan's costs.)
Messages should be simple and repeated often by someone who has high credibility with the audience.
A study by the Center for Health Care Strategies, "Medicaid Efforts to Incentivize Healthy Behaviors" demonstrated that Medicaid beneficiaries were less effective in sticking with long-term behavior change without additional support. Here are a few other issues noted in the research:
Member has to be interested or at least contemplating change
Member must see the value in what is being initially required and any long-term benefits
Long-term change requires conversion from extrinsic to intrinsic benefit
Perhaps most importantly, the action that the person is being asked to take must be achievable. The program must address the most critical barriers, or perceived barriers, that the member may face.
These barriers can include a lack of specialist availability, transportation, and daycare; social stigma, fear, denial or ignorance; and economics. To address these barriers and others, it's critical to offer a complete member engagement program where one of the strategies is incentives.
Complete Approach to Member Engagement
Incentives are just one part of a complete member communications approach to reaching consumers. A comprehensive program includes a number of ways to encourage consumers to join and remain in a program. These include:
Member communications
Provider and community outreach
Addressing barriers to care
Incentives
Measuring success
Refining the program
Case Studies
Both organizations, Illinois Medicaid and a commercial health plan, highlighted here implemented consumer incentives in partnership with McKesson.
The Illinois Department of Healthcare and Family Services (HFS) and McKesson developed an incentive program to encourage participation of eligible high-cost, high-risk Illinois Medicaid recipients in the Your Healthcare Plus care management program.
As part of the ongoing outreach activities, a re-contact letter is sent to members not yet actively participating promising a $10 Walgreens gift card if the member completes an assessment, thereby officially enrolling in the program. The letter also asks the member to verify demographic data.
The re-contact letters were sent multiple times over the course of many months. The results of the first year of the incentive program show that members who received the enrollment offer generated a 20% enrollment rate, while members who received a letter without the enrollment offer, generated a 13% response rate.
While the initial results were positive, HFS and McKesson are now refining the program further by adding an end date to the offer to improve tracking to create a sense of urgency; limiting the number of letters sent per member—identifying the point of diminishing return; and adding disclaimer language to discourage members from requesting multiple gift cards.
Meanwhile, a Texas commercial health plan that wanted to improve the enrollment in its asthma and diabetes care management programs used a $10 gas card as an enticement. The health plan sent two similar mailings to two groups of 1,200 members each:
One group received program information and a letter letting them know that when they successfully enrolled in the program a $10 gas card would be sent to them.
The control group received program information with no mention of the free gas card.
The program lasted one month.
While the program enrollment numbers are small, the results of the incentive program showed that the gas card offer did have a positive impact on member enrollment.
Of the 10 people who enrolled in the asthma program during the 30-day incentive program, 70% came from the incentive group, the remainder from the control group. The story was much the same for the diabetes group. Of the 30 people who enrolled during the incentive period, 73% were from the incentive group, 27% from the control group.
The program demonstrated that those in the incentive group were 2.67 times more likely to enroll than control group members.
Finding Success
Success is measured with qualitative and quantitative assessments. We typically look at response rates, and retention or enrollment rates to find out how well the program is accepted by members. We also look at complaints, compliments, and anecdotal feedback received by staff members.
For specific chronic illness or other conditions that we want to impact, we'll drill down to get screening rates and HEDIS scores.
We also look closely at how well we're doing. How much does the program cost, including direct costs, such as creative development, print and postage, incentives, and call center support?
Across the board, we've found that successful member engagement programs have several things in common:
The program is simple.
Multiple channels are used to communicate with members.
The message, whether it's joining the program or quitting smoking, is reinforced throughout the course of the program.
Jim Hardy is senior vice president/general manager at McKesson Health Solutions, a provider of care management services to commercial and Medicaid clients.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
Private health insurance leaders are pushing Congress to allow insurers to benefit from the Medicaid Drug Rebate Program, which lets states pay less for drugs in their Medicaid program.
There are two reasons behind the insurers' plea: a desire to improve the bottom line and a need to improve care coordination.
The drug rebate was created in 1990 and requires drug manufacturers to enter into an agreement with HHS to offer the rebate to Medicaid state programs. In 1992, the rebate program was extended to include the Veterans Administration.
Approximately 550 pharmaceutical companies participate in this program, which is available in 49 states and the District of Columbia, according to CMS.
The current law, which would be changed if legislation on Capitol Hill is approved, forces states that partner with private insurers to make a tough decision. Do they save money and carve out pharmacy from their Medicaid managed care programs that are run by private insurers? Or, do they keep pharmacy within private health insurers' Medicaid programs and gain the benefit of better care coordination, while losing out on the rebate?
States that want to take advantage of the drug rebate have carved out pharmacy programs from their private insurer-run Medicaid managed care plans, but these plans don't integrate immediate pharmacy benefit information because pharmacy is carved out of the program in order to benefit from the drug rebates. Private insurers say this leaves out an important piece of care coordination.
For instance, in going with a private insurer as opposed to carving out the program, when a Medicaid beneficiary is placed on a particular medication, the private health plan can find out immediately and enroll the member in a disease management or wellness program. With pharmacy carved out of the program, there could be a lag or the health insurer might not have access to that information at all.
In the struggle to find savings that don't involve program cuts and layoffs, it's easy to understand why states are carving out pharmacy from Medicaid managed care. The tough economy makes it critical for health insurers to push for change in the Medicaid Drug Rebate Program because more states will surely look under every rock to find savings and sometimes at the detriment of providing an integrated program that benefits from receiving clinical, claims, and pharmacy data.
The Obama administration has targeted the Medicaid Drug Rebate Program as a potential area of savings and calling for a reduction of $8.8 billion over five years by mandating increased Medicaid drug rebates. With the rebate on the table, this is an opportunity for health insurers to promote why they too should receive drug rebates—and that is exactly what they are doing.
America's Health Insurance Plans President and CEO Karen Ignagni said Medicaid managed care plans should receive the same drug rebates because they are in effect working as state agents.
J. Mario Molina, MD, chairman and CEO of Molina Healthcare, which covers more than 1.3 million Medicaid lives in 11 states, said roughly half of Medicaid beneficiaries are covered under managed care plans, which shows the rebate's importance to insurers and states.
As the health insurance industry converges on San Diego for its annual AHIP conference this week, healthcare reform tops the agenda. The discussion has focused mostly on the public insurance option, but health insurers involved in Medicaid should also keep their eyes on Medicaid Drug Rebate Program legislation and work to integrate rebate changes into the larger healthcare reform package.
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Many businesses are interested in employing social media to their benefit but there are a number of challenges that make social media a challenging proposition. One of them is making social media sustainable. As exciting as it can be to start using Facebook, Twitter, and other popular social media websites, excitement usually wears off fast and many businesses struggle to sustain their social media efforts, according to this blog post. Here are some tips for making sure your business doesn't get social media burnout.
When people talk about the "death of public relations," they are talking about the death of media relations. That's what PR has been all about for the past 50-odd years. After all, during that era, the only way to reach the masses in a reliable way was through mass media. Now that that's changing, our approach can change.
Digital media are changing the environment for communicating health information. In a new book, University of Missouri journalism researchers say effective health communication can significantly enhance healthcare and public health as well as reduce inequities in people's access to health information and services.
Every staff member—from physician leaders to student nurses—shares the same rallying cry at MultiCare Health System in Tacoma, WA. The phrase can often be heard reverberating throughout the hallways as they remind each other of their common objective: "Gel in, gel out." Their goal? Infection control.
The hospital's internal communications team has navigated many avenues to educate hospital staff members about the importance of hand hygiene. It has promoted hand washing in daily print and online publications, handed out flyers, posted hygiene compliance rates, suggested talking points to unit managers, and distributed stickers. And if all that doesn't work, the CEO personally gives offending units a call.
MultiCare began its current hand washing campaign in 2005 when the Washington State Hospital Association (WSHA) launched a statewide hygiene effort. Since the program's implementation, MultiCare's hand hygiene percentages have jumped from about 40% to more than 90%. The hospital has won the WSHA "Best Hands on Care" award for two years running.
Tamyra Howser, internal communications manager, attributes the campaign's success to the teamwork between her staff and infection prevention and control.
"We knew it was an important initiative, so we worked directly with [the] infection control and quality [departments] to make sure this message was spread throughout the system," Howser says.
Another element contributing to the hospital's hand hygiene success is the visibility of the infection control staff, says Marcia Patrick, director of infection prevention and control.
"They're out there, they're engaged, they're very visible to the staff, and I think that makes a huge difference," Patrick says. "It's just that constant focus that people know that we're watching. People know that we are concerned about this, and the other big thing is getting people to understand that patients expect this."
By practicing interdepartmental teamwork and promoting marketing materials alongside internal communication techniques, MultiCare's staff hand washing practices began to transform.
One of the nurse managers began reminding her staff members to sanitize their hands with a saying that would soon become the hospital's hygiene catchphrase: "Gel in, gel out."
Once the internal communications team realized how strongly the motto was resonating with staff members, it began installing new sanitizing gel stations with "gel in, gel out" labels, says Howser.
"It didn't take a lot for it to catch on with the clinicians that this is important," she says. "The CEO wants it, and also we know this is the best care for our patients."
"Like anything, change is difficult," Patrick says. "But when you can post their graph with staff compliance for the most recent month, it gets people's attention. It may even be subliminal messaging. They see the lines going down and then think, ‘I better buff this up a little.' "
OK, so there's been a lot of buzz—and a lot of articles—about hospitals that are using the micro-blogging site Twitter to describe surgeries in real time. There's also been a lot of debate over whether or not this is a good idea.
In a recent guest post on our MarketShare blog, Patrick Buckley reported about the negative reactions to tweeting surgeries in an online poll ("Milwaukee Not All A-Twitter Over Hospitals' Use Of Social Media.") The responses, overwhelmingly negative, annoyed me. "They should be focusing on the patient who's 'under the knife,'" one respondent wrote. "Distractions can cause problems. No one wants to hear 'oops' during surgery."
To borrow a line from the Saturday night live skit, "Really? With Seth and Amy:" Really?
Do people really think that surgeons would really put down their scalpels and skip over to the computer to post their 140-character updates? Do people really think that any healthcare organization would put Twitter before patient safety? Really?
Meanwhile, it doesn't matter that these readers were woefully uninformed (I blame the publication in part for that because the poll simply asked whether tweeted surgeries are a good idea without explaining how they work). The fact is that healthcare marketers can't just jump onto the Twitter bandwagon without having a solid communications plan and marketing strategy in place and also explaining clearly what they're doing.
They must balance the benefits of the effort—increased exposure, possible media coverage, an opportunity to educate patients who might be facing the same type of surgery—with the negatives—people who don't really understand social media throwing stones because they think it's clever to pooh-pooh anything new.
For a look into one tweeting hospital's experience, I interviewed Marc Battaglia, associate creative director at Demi & Cooper Advertising in Elgin, IL. The agency worked with Chicago's Sherman Health, a multi-hospital system, to tweet a laproscopic hysterectomy. Battaglia understands the risks and benefits of trying something new, but does a good job articulating why the benefits outweigh the negatives. Excerpts from our Q&A session follow:
Gienna Shaw: What was the thought process that led to Sherman Hospital tweeting the surgery?
Marc Battaglia: Twitter is an amazing platform if you look at it as we do. We see Twitter as a multi-device real-time messaging system. That means when you send out a message on Twitter it can be delivered in real-time to a user's gadget of choice, whether that be their desktop computer at work, their laptop in a coffee shop or their BlackBerry or other wireless device. Sharing information from an OR is not a new idea. Twitter is a perfect medium for distributing information from an OR because it allows time for messages to be worded correctly.
We were looking for new ways to help Sherman connect with their community, to provide information, and help people become more familiar with the hospital. We found that Tweeting the surgery was an excellent way to help potential surgical candidates become more comfortable with Sherman.
The surgery that was performed at Sherman Hospital was a laproscopic hysterectomy, which, as you can imagine, is a complicated procedure. The procedure was even more unique in that it was done with the da Vinci Surgical Robot, a truly incredible piece of technology. Some of the benefits of this type of procedure are the incredibly small incisions, less blood loss, and a speedier recovery time. The surgery was led by Raja Chatterji, MD, and Humberto Lamoutte, MD, both OB/GYNs and surgeons on the medical staff at Sherman Hospital, both highly trained on the da Vinci Surgical Robot.
GS: What were the benefits of doing the surgery? What were the risks?
MB: The first surgery to be Tweeted was done by Henry Ford Hospital in Michigan. Having them come before us helped Sherman understand what was involved. We were the second hospital to do this, the first in Illinois and the first ever to simulcast on Twitter and Facebook. Since then there have been several other hospitals that have Tweeted surgeries and all have been great successes.
Our main concern was getting approval from the patient. Luckily we were able to find several patients who were excited about participating. The doctors narrowed it down to one patient based on logistics, surgical complexity, and timing. Since the doctors felt comfortable that the patient would be an appropriate choice for this surgery, the second concern for us was centered around technology. We brought in our own equipment, which included two MacBook Pros, two iPhones, a HD video camera, mini-DV camera, and a digital SLR camera. In addition to tweeting details on the progress of the operation and answering questions from our community and around the world, we were able to take near-realtime photos and upload high-def video to YouTube within about three minutes.
The response to the surgery was overwhelmingly positive. We had people watching from all over the world and then coverage followed from every major media outlet in Chicago, as well as newspapers, magazines, and trade journals from across the country.
As with anything new, there are risks involved, and the Internet has made it easier than ever for comments to be shared. Some people were confused about the surgery and were concerned that the doctors were putting down their scalpels to Tweet. Others thought it may be a violation of privacy for the patient, not realizing that, of course, we had permission. The patient's family was very excited and watched the surgery on a BlackBerry from the waiting room, which they felt was a huge comfort. Part of our job is to also help with reputation management and education.
GS: If you could tell hospital leaders one thing about using social media (especially if they are hesitant or skeptical about it), what would it be?
MB: Social media isn't going to go away, and ignoring it isn't really a viable option. The best way to manage your reputation online is to participate. Ignoring it is a short-lived strategy. Hospitals and healthcare facilities need to become involved and present helpful, safe, and accurate information.
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