Boston-based Beth Israel Deaconess Medical Center, which laid off about 70 workers last month and made other cuts to regain its financial footing, is now taking other steps to stem a projected $28 million loss this year in its biomedical research operations. The expected deficit is forcing the teaching hospital to give up lab space in two buildings and consolidate its research at a single site. Hospital officials blame the projected loss on lower-than-expected funding from the National Institutes of Health and a costly lease arrangement it made about five years ago at a new research building.
Four HIV-positive patients whose records were left behind on an MBTA train by a Massachusetts General Hospital employee are suing the hospital, contending their privacy was breached. In March, the hospital notified 66 patients who received care at its Infectious Disease Associates outpatient practice that billing records bearing their names, Social Security numbers, doctors, and diagnoses had been lost by a manager who was riding the train. Four of the 66 patients filed a breach-of-privacy suit in Suffolk Superior Court against the hospital and the unidentified billing manager.
Republican lawmakers stepped up their opposition to Democrats' plans for overhauling the nation's healthcare system by introducing legislation that would give Americans tax credits to pay for health insurance. The plan offers a glimpse into how the GOP is mobilizing against Democrats' effort to create a public insurance plan and to require companies to provide or otherwise pay for health-insurance coverage for workers. Republican lawmakers say such measures would bureaucratize the nation's health system and stifle job creation.
Medicaid managed care is providing a safety net of care coordination to millions of at-risk Americans and is improving patient outcomes and quality of care, while reducing states' healthcare costs, according to a recent Lewin Group report that was prepared for America's Health Insurance Plans.
A state looking to cut Medicaid costs should not reduce benefits or lower payment rates, but should instead expand its managed care program, according to the report.
The Lewin Group released a similar study five years ago and returned to the same subject, achieving similar results. In its latest report, The Lewin Group reported Medicaid managed care health plans improve beneficiaries' access to services and have earned high satisfaction ratings from enrollees, in addition to improving care and saving money.
The researchers pointed out that while nearly half of Medicaid beneficiaries are enrolled in managed care plans, more than 80% of national Medicaid spending is in the fee-for-service setting.
AHIP President and CEO Karen Ignagni says Medicaid managed care plans coordinate care, offer patient outreach not available in fee-for-service Medicaid, provide focused chronic care and disease management programs, offer preventive services, and give non-healthcare assistance to beneficiaries in areas such as finding alternatives to nursing home care.
"The bottom line of The Lewin Report is that we are providing high value and cost-effectiveness for states at this time of economic crisis," she says. "At this time, we are providing better quality, more access, and a higher degree of satisfaction to beneficiaries than traditional Medicaid programs. That's quite a legacy."
After analyzing 24 recent studies of Medicaid managed care programs, The Lewin Group reported that:
The studies strongly suggest that the Medicaid managed care model typically yields cost savings. The results ranged from 0.5 to 20% savings compared to FFS Medicaid.
The studies provide some evidence that Medicaid managed care savings are significant for the Supplemental Security Income and SSI-related population.
Various studies demonstrated that states' Medicaid managed care cost savings are largely attributed to decreases in inpatient utilization, which could be linked to care coordination.
Medicaid managed care plans yielded "noteworthy savings" in pharmacy. In comparing FFS programs' drugs costs versus Medicaid health plans, researchers found the costs per-member per-month were 10% to 15% lower for the private health plans.
James Carlson, president and CEO of AMERIGROUP Corporation, which covers 6.7 million Medicaid beneficiary lives in 14 states, says care coordination helps millions of Americans who would otherwise be lost in the healthcare system. He adds more states understand the benefits of Medicaid managed care.
"I do think that we as an industry have matured to the point that the states understand that these programs have to be reasonably well funded because it would cost more if they didn't have us ... More often than not, we're finding states that appreciate the involvement of the private sector," says Carlson.
Not every state has been satisfied with its Medicaid managed care program. This has been most notably the case in Florida. However, other states have experienced more positive results, which The Lewin Group highlighted.
The Lewin Group wrote, "It is clear that—through carefully crafted managed care program design that is tailored to the state's Medicaid populations and geographic landscape—real opportunities exist for states to benefit from expanding the Medicaid managed care model to eligibility categories and services heretofore largely excluded from managed care."
Rather than cutting eligibility, eliminating benefits, or reducing provider payments, The Lewin Group and Medicaid managed care supporters say states should instead look to expand these programs, given current budget pressures.
Given these positive results, Ignagni says AHIP supports a plan that would allow anyone under 100% poverty levels to be eligible for Medicaid. Those levels now vary by state and are not strictly based on income level.
Carlson also suggests that states change laws that would allow Medicaid beneficiaries to not have to recertify their eligibility every six months.
California has imposed its sixth round of fines against hospitals for serious mishaps and so-called never events, such as fatal errors with high-risk medications, surgery on the wrong patient and three cases in which objects were left inside patients during surgery.
One hospital was fined for not promptly investigating an alleged sexual assault by a staff member against a patient.
Other reasons for the punitive actions by the California Department of Public Health, which licenses about 450 acute care facilities throughout the state, were failure to properly transfuse a patient and the incorrect use of respiratory equipment.
Administrative penalties of $25,000 were assessed on the facilities for events occurring in 2008. Incidents that occur after Jan. 1, 2009 will be fined $50,000.
These penalties will bring $350,000 to the state to implement better safety strategies in acute healthcare settings. Since the law allowing hospitals to be assessed a monetary fine took effect in 2007, 87 fines have been levied against 59 hospitals, for a total of $2.175 million, said department director, Kathleen Billingsley.
About $1.2 million has so far been collected. However, 18 of the hospitals are still appealing their fines.
Billingsley said that far from just "showcasing" hospitals that made serious errors, the public announcements of these penalties prompts all hospitals to improve. "The hospitals go back and say 'Wait a minute. Do we have a process to prevent this from happening here?'" she said.
As a result of knowing how things go wrong, "the best practices are being developed and have been developed." Much of the time, she added, "it's a process breakdown" which prompts the hospitals "to put in additional checks and balances to make sure something like it doesn't happen again."
The state is using the fines to fund safety and error prevention programs. Billingsley's department is in the process of analyzing the errors and their underlying causes, and will at some point issue a report.
The hospitals assessed fines in this announcement include Brotman Medical Center, Hollywood Presbyterian Medical Center, Harbor-UCLA Medical Center, Saint Francis Medical Center, and Whittier Hospital Medical Center in Los Angeles County; St. Jude Medical Center, University of California Irvine Medical Center in Orange County, which received two fines; and University of California San Diego Medical Center and Scripps Mercy Hospital in San Diego County.
Fines were also levied on Clovis Community Medical Center and St. Agnes Medical Center in Fresno County, John Muir Medical Center in Contra Costa County, and the University of California San Francisco Medical Center in San Francisco County.
The specifics problems were:
At Whittier Hospital Medical Center in Los Angeles, the wrong patient was taken for surgery a dilation and curettage procedure, resulting in the operation being initiated in a 63-year-old patient with colon cancer, who was scheduled for a Port-a-Cath device for chemotherapy. The operation "was terminated when found that the patient did not have a uterus." The arm-band was not checked, the "time-out" was described as "quick," and there was no documentation that correct side/site checks were performed. Also the patient had been put to sleep prior to the "time out," contrary to anesthesia protocols.
At Brotman Medical Center in Culver City, a patient received hydromorphone by intravenous push rather than subcutaneously as prescribed, resulting in the patient going in to a coma and requiring mechanical ventilation. The patient had been admitted to the hospital for a colon resection. An investigation determined that hydromorphone syringes were improperly labeled and their administration in at least two patients was not independently verified by a second nurse, as hospital policy requires.
At Clovis Community Medical Center near Fresno, lack of communication between two physicians and the failure to check an INR (international normalized ratio) test for a patient resulted in potentially adverse effects from the anti-clotting drug warfarin, which conflicted with amiodarone, another drug the patient was taking.
At Hollywood Presbyterian Medical Center in Los Angeles, a patient received the wrong blood type because a staff member went to the wrong patient's room. The error caused a dangerous hemolytic reaction that resulted in the patient's death.
At John Muir Medical Center in Concord, the failure to properly restrain a patient for a radiology exam resulted in a fall that caused a ruptured right eyeball. The result was that the patient became blind in that eye.
At Los Angeles County Harbor UCLA Medical Center, a surgical sponge was left in a patient for more than 10 months, despite the patient complaining of pain, nausea, and vomiting. Another surgery was required to remove the sponge and a cyst that had formed around it.
At Saint Agnes Medical Center in Fresno, the facility's third such penalty, was assessed after a patient died following surgery because staff did not intervene quickly enough to remedy her abdominal hemorrhaging after a hysterectomy.
At St. Francis Medical Center in Lynwood, potassium levels weren't monitored in two patients resulting in cardiac emergency. One of the two patients died.
At St. Jude Medical Center in Fullerton, a plastic drape or towel used to guard a sterile field was repositioned by the surgeon to retract the patient's bowel and subsequently became hidden in the patient's body cavity. The drape was not counted like other devices, such as sponges or surgical tools. "After the patient went to the recovery room Surgeon D called Nurse B to ask 'did we remove the drape?' Nurse B stated she told the surgeon she did not remember the drape being removed," the statement of deficiency says. Removing the drape required a second surgery requiring intubation, that carried additional risk of respiratory problems, increased blood pressure or heart rate, damaged teeth, lips and swelling, or injury to the throat or larynx.
At Scripps Mercy Hospital in San Diego, faulty respiratory equipment was used to provide ventilation support to a trauma patient with a brain injury on Sept. 1. Also, the hospital failed to make sure that the patient's respiratory status was checked by a licensed nurse and respiratory therapist during transport of the patient to a portable MRI unit located outside the facility. When the patient was administered vecuronium and sedated for the MRI, the patient went into respiratory and cardiac arrest. An investigation determined that the transport ventilator lacked the "on/off" knob and the "pressure relief knob and had not been maintained since April."
At the University of California Irvine Medical Center, hospital officials failed to promptly investigate an incident involving a patient's complaint that she was sexually abused by a staff member. "The facility failed to ensure the safety of other patients by allowing the alleged abuser continued contact with other patients after the reported allegation," the state's record says.
At the University of California Irvine Medical Center, staff failed to watch a patient at risk for falling, who subsequently got out of bed and fell, sustaining a fatal laceration to the back of the head. The laceration was so severe that the patient's blood pressure subsequently dropped, he lost consciousness, which he did not regain. Staff also failed to take precautions, such as making sure that a walker was left in the room for the patient's use or that non-skid socks were on his feet.
At the University of California San Diego Medical Center, surgeons operating on a patient for lumbar stenosis left a Raytec (x-ray detectible) surgical sponge in her spine area, which wasn't discovered for three months. The facility failed to follow its own procedures, which required that post-surgical x-rays be taken to make sure all foreign objects had been removed. A second surgery was required to remove the sponge.
At the University of California San Francisco, failure to establish safety standards for administering Flolan, a drug that opens up blood vessels in the lung in patients with pulmonary hypertension. The mishap resulted in a patient receiving 23 times the prescribed dose, which proved fatal. The infusion device did not meet manufacturer's recommendations and one registered nurse with no validated competency in using the device was assigned to provide the patient's care.
Last year, a Joint Commission review at 15-bed Cross Ridge Community Hospital in Wynne, AR, found unacceptable a practice by which a daytime pharmacist retrospectively reviewed nighttime prescription orders after they were administered.
In St. Louis County, Minnesota, 25-bed Ely-Bloomenson Community Hospital was having trouble recruiting pharmacists because of a requirement they be on call at all times.
At Atoka Memorial Hospital in Oklahoma, officials assumed there were very few medication errors taking place at the 25-bed facility. They soon discovered that was not the case.
And in the Black Hills of South Dakota, 18-bed Lead-Deadwood Regional Hospital had to depend on pharmacy services from 40-bed Spearfish Regional, 15 miles away, a situation that was "untenable as Lead-Deadwood was often dependent on Spearfish's priorities," according to a new report on the use of telepharmacy in rural areas.
These four critical access hospitals in very rural regions of the nation are among some 20 small acute care facilities that are solving their problems with the use of such technologies in an effort to improve the way they dispense medications to their patients. Their situations, and the reasons for executive decisions to transition to remote prescription services, are described in a new report from the Upper Midwest Rural Health Research Center.
The study, "Implementation of Telepharmacy in Rural Hospitals: Potential for Improving Medication Safety" concludes that while such electronic technologies hold high promise for improving quality, very few systems have implemented them in part because of lack of state regulatory guidance or support.
"The use of telepharmacy technology to provide pharmacist services to rural hospitals is not widespread," the report cautioned. Nevertheless, some of the hospitals that have implemented it "have seen improvements in their medication error rates." Additionally, some are tracking whether telepharmacy affects accuracy of order entry, turnaround time, number of after-hours orders, productivity of staff, overrides of automatic dispensing machines and billable revenues.
The lead author, Michelle Casey of the University of Minnesota, defines telepharmacy as the process by which a small rural hospital faxes or otherwise transmits by electronic means a medication order for review by a pharmacist at another hospital. Telepharmacy can involve the use of medication dispensing equipment that is remotely controlled, or long-distance supervision of pharmacy technicians by a pharmacist at another site, perhaps through audio-visual equipment.
For example, a pharmacist service might be shared among hospitals in the same healthcare system, or in different healthcare systems. Or hospitals may join together to contract for telepharmacy services with a commercial telepharmacy company.
Several studies have concluded that such strategies can greatly improve medication safety in rural hospitals. Nationally, there is a growing shortage of pharmacists, but nowhere is that supply as lopsided as it is in remote parts of the country.
Telepharmacy helps resolves the challenge of getting pharmacists to review orders on an as-needed urgent basis when they otherwise would have to drive 45 miles across rugged mountain roads to get to the hospital.
Today, Medicare does not require critical access hospitals to have a minimum level of pharmacy staffing, only to have "pharmaceutical services that meet the needs of the patients" and "a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision," the report said.
Joint Commission rules setting standards for hospital pharmacists are irrelevant for some critical access hospitals that don't seek accreditation, the report said.
The burden of setting hospital telepharmacy standards is left to each state's Board of Pharmacy, which must decide how many hours of pharmacy coverage should be minimally required, the physical location of a pharmacist providing telepharmacy services (such as whether a pharmacist can review orders from his home or from another facility), the types of technology that should be used, the minimum time that a pharmacist must be physically at the hospital, and the roles of pharmacy technicians and nurses.
The report's authors interviewed officials at nine state pharmacy boards and summarized the varying policies or lack of policies, at each.
Until recently, the report said, "the primary focus of telepharmacy regulation (by state pharmacy boards) has been on retail settings."
Boards may also be challenged with deciding whether to limit telepharmacy applications to only those hospitals that are truly in rural areas, with only a dozen or so people per square mile.
Market forces have also been an impediment to implementation, the report said. "Competing interests may come into play and provide barriers...Because of competition with commercial pharmacies, current rules governing outpatient pharmacies are very restrictive."
The report described a situation in Texas, where state rules say a hospitals with more than 100 beds must have a pharmacist on duty at all times the pharmacy is open, but smaller hospitals may have part-time services where a pharmacist must visit the facility at least every seven days.
Having a pharmacist provide long-distance supervision of pharmacy technicians at a rural hospital has not been allowed, except through a pilot project run by a commercial company, Envision Telepharmacy.
Envision provides remote order review and entry, after-hours medication provision, electronic supervision of pharmacy techs and after-hours drug information and consultation.
However, the report said, "It was to recruit hospitals into the Envision telepharmacy pilot. Many hospitals had been operating in violation of state board of pharmacy regulations, but were not being cited. For some hospitals, it was a case of not wanting to solve a problem until it became one."
About half the hospitals funded their initial telepharmacy project expenses with state, federal and private foundation grants. Other hospitals funded them from operating budgets. But other hospitals said lack of funds was a barrier to purchasing the latest dispensing equipment.
The need for creative electronic solutions should only increase, said the report's author Casey. Rapid growth in the volume and complexity of hospital medications, expanding duties for pharmacists to manage medications, the rapidly evolving nature of audio visual technologies will make telepharmacy strategies a natural solution for rural hospitals.
The report concluded, "State regulations that allow rural hospitals to make appropriate use of pharmacy technology are needed if telepharmacy is to realize its potential for increasing access to pharmacist expertise in rural hospitals and helping to achieve the overall goal of improving medication safety.
As many as one in five women diagnosed with breast cancer had lesions that were visible but overlooked on most recent mammograms, and another 10% to 20% had lesions that were misinterpreted, according to a report summarizing recent research on cancer in women.
The synopsis was prepared by the Agency for Health Research and Quality in an effort to improve diagnoses, assure appropriate referral, and optimize the use of proven therapies for women with breast, cervical, ovarian, colon, and lung cancer.
Another important finding was that facilities that have the highest accuracy rates in detecting breast cancer offered only screening mammography, the routine exams that look for abnormal findings in all women, not diagnostic mammograms which attempt to interpret those abnormal findings.
"They had a breast imaging specialist on staff, and conducted audits of radiologists' performance two or more times per year," the report said.
The report also points out that so far, evidence suggests radiation therapy following breast-conserving surgery for a primary breast cancer reduces the risk of recurrence, but has only a small overall increase in survival. But, not performing radiation therapy after the primary cancer develops in the other breast appears to double the risk of dying.
"Women who did not receive radiation had slightly more than twice the risk of dying from breast cancer and 1.7 times the risk of dying from all causes as women who received radiation."
Some breast cancer surgeons at six New York hospitals do not encourage adjuvant treatment in one-third of a sample of 119 breast cancer patients, despite the fact that such treatment—including radiotherapy, chemotherapy and hormonal therapies—is recommended.
The report also pointed to a potential racial bias among oncologists in how they communicate with breast cancer patients. After videotaping visits of 405 women newly diagnosed with breast cancer during their visits with 58 oncologists, the researchers found that the doctors spent more time and "engaged in building relationships" with white women more than women of other races.
The Society for Human Resource Management has come out against a proposal that would require companies with 15 or more full-time employees to provide seven days of paid sick leave each year. Instead of the mandates set down in the recently introduced Healthy Families Act, SHRM says Congress should craft consensus legislation on workplace flexibility.
"We believe that employers should be encouraged to offer paid leave as part of every full-time employee's benefit plan – but we oppose an inflexible, one-size-fits-all government mandate," says Laurence O'Neil, SHRM President and CEO. "Our goal is to seek legislation that will encourage paid leave, but not discourage the creation of quality new jobs."
The bill is sponsored by Sen. Edward Kennedy, D-MA. Inquiries to his office were not immediately returned.
SHRM says the Healthy Families Act would also lock in existing leave benefits and limit or eliminate an employer's flexibility in making even minor adjustments in leave provisions. O'Neil says this could be a major burden for employers that tailor leave policies to meet an individual employee's needs. Any federal mandate that restricts an employer's ability to offer such voluntary leave policies could work against employees.
SHRM says a federal policy on workplace flexibility should:
Encourage employers to offer uniform and coordinated paid leave;
Create administrative and compliance incentives for employers who meet the leave standard;
Provide certainty, predictability and accountability for employers and employees; and
Allow for different work environments, industries and organizational size.
Due to multiple media channels, new technologies, and consumers who have a short attention span, traditional communications are no longer sufficient for creating loyal fans or bringing a brand to the forefront. This new reality demands a new approach to engaging consumers, and this is where corporate social responsibility as branded content comes in.
Derrick Dockery, a 330-pound offensive lineman for the Buffalo Bills football team, stands dressed in full uniform holding his helmet under one arm. But instead of wearing his usual game-face grimace, Dockery is smiling. Next to his image, the ad reads, "I protect the quarterback . . . you protect your heart!"
The ad promotes Buffalo (NY) General Hospital's Chest Pain Center, a program Dockery has promoted since December 2008. The hospital has been marketing partners with the Bills for three years, and its marketers knew they needed a noteworthy player to represent the hospital's heart services in 2009.
"I wanted someone who could speak from the heart, no pun intended, about cardiac awareness," says Michael Hughes, vice president of public relations at Kaleida Health, Buffalo General's health system. "We wanted someone who could legitimately talk about the importance of heart health and cardiac awareness."
After talking with the Bills' coaches and trainers, Hughes learned that Dockery's family has a history of heart disease. His grandfather died of a heart attack and his mother and father-in-law have had cardiac episodes.
Hughes and his team met with Dockery, interviewed him and his wife, and gave them a tour of the hospital. The marketing team then coordinated a TV spot, two radio spots, and the print ad.
The 30-second TV ad features Dockery advising viewers to call 911 if they feel any kind of chest pain. "Sometimes the source of chest pain is obvious," Dockery says over a clip of a football player being tackled. "And sometimes, it isn't," he says over a clip of an office worker clutching his chest.
After Dockery introduces himself and tells viewers to call an ambulance if they experience any heart attack warning signs, the commercial ends by saying it was made by Buffalo General and Kaleida Health, an "all star-team that tackles heart problems."
Hughes says that Dockery's message has resonated well with the community because heart disease has personally affected him.
"We've gotten an awful lot of positive feedback because he's someone that speaks from experience, understands the importance of this," Hughes says. "We just don't look at it as an advertising venue, we look at it as a marketing and community relations tool."
Hospitals should look into using a local celebrity to promote their facilities, provided they have the proper service lines and community environments to do so, Hughes says.
"It's unique based on the cardiac initiative that we have," he says. "It's not a be-all-end-all, but for us, it's just another piece of the marketing puzzle."
