As the Obama administration wrestles with how to expand healthcare coverage to the millions of uninsured Americans, some organizations are finding creative ways to help cover employees of small businesses. The programs typically involve collaboration between business owners, nonprofit groups and local hospitals, which offer enrollees a range of medical services at a reduced rate. The plans keep costs down partly by bypassing the extra costs that come with traditional insurance. That can be a big help for small-business employees who can't afford traditional insurance, but for patients with costly chronic diseases or catastrophic illnesses, the coverage would likely be inadequate.
Free pens litter doctors' offices all across New York, part of an often-criticized strategy by drug company sales representatives known as detailers, who traditionally go from waiting room to waiting room giving gifts to entice doctors to prescribe their products. Now in New York City, there is a new kind of detailer: people who are part of a campaign by the city to use pharmaceutical industry marketing savvy to spread the word about healthy practices to doctors in neighborhoods where patients often have the least access to the latest news in healthcare. In the last 10 months, the city has spent nearly $900,000 on half a dozen detailing campaigns, including ones about influenza and pneumococcal vaccine distribution and education, colon and rectal cancer screening and smoking cessation.
Although the illness is difficult to track, health officials estimate that in the United States Clostridium difficile cause 350,000 infections each year in hospitals alone, with tens of thousands more occurring in nursing homes. While the majority of cases are found in healthcare settings, 20% or more may occur in the community. The illness kills an estimated 15,000 to 20,000 people annually. The rate of C. difficile infection among hospital patients doubled from 2001 to 2005, according to an April 2008 report from the CDC.
CMS today announced the 14 communities around the nation that have been picked for its three-year pilot project to eliminate unnecessary hospital readmissions that cost Medicare billions of dollars annually in preventable care.
A study published this month in the New England Journal of Medicine found that nearly 20% of Medicare patients in 2003-2004 were back in the hospital within 30 days of a discharge, and that 34% were rehospitalized within 90 days. The study estimated the cost of the unplanned rehospitalizations in 2004 at $17.4 billion.
"Our data show that nearly one in five patients who leave the hospital today will be readmitted within the next month, and that more than three-quarters of these readmissions are potentially preventable," CMS Acting Administrator Charlene Frizzera says. "This situation can be changed by approaching health care quality from a community wide perspective, and focusing on how all of the members of an area's health care team can better work together in the best interests of their shared patient population."
The Care Transitions Project sites will operate in: Providence, RI; Upper Capitol Region, NY; Western Pennsylvania; Southwestern New Jersey; Metro Atlanta East, GA; Miami; Tuscaloosa, AL; Evansville, IN; Greater Lansing Area, MI; Omaha, NE; Baton Rouge; North West Denver, CO; Harlingen, TX; and Whatcom County, WA.
The Care Transitions Project will continue in all 14 communities through summer 2011.
CMS says the pilot project is designed to improve healthcare processes so that patients and caregivers have the tools, training, and procedures the need to reduce unnecessary readmissions. The program will promote "seamless transitions" from the hospital to the home, skilled nursing facility, or home healthcare.
While hospitals have been supportive of the idea of reducing hospital readmissions, many executives are concerned about a CMS plan to reduce reimbursements for hospitals with high readmission rates. Ed Hannon, CEO of McDowell Hospital in Marion, NC, and president of the American Hospital Association's Small or Rural Hospitals Governing Council, says that many readmissions are beyond the control of hospitals. He says that smaller hospitals with lower patient volumes could be particularly hard hit if only a handful of patients are readmitted.
Hannon told Congress last month that the effort to save about $8 billion by trimming payments to hospitals with high 30-day readmission rates may be a one-size-fits-all solution to a complex series of problems. "Any provision that does not recognize legitimate reasons for readmission may become an obstacle to patient care and safety," he says.
Barry M. Straube, MD, CMO for CMS, says the pilot project will look at the particular needs and resources in each of the 14 communities. "Rather than focusing on one global problem and trying to apply a one-size-fits-all solution across the country, Care Transitions experts will look in their own backyards to learn why hospital re-admissions occur locally and how patients transition between health care settings," says Straube, who is also director of CMS' Office of Clinical Standards & Quality. "Based on this community-level knowledge, Care Transitions teams will design customized solutions that address the underlying local drivers of readmissions."
CMS will monitor the success of this project by watching the rates at which patients in these communities return to the hospital. Readmission rates for hospitals have been tracked by CMS for some time, and will be available to consumers later this year through the Hospital Compare Web site at www.hospitalcompare.hhs.gov.
Each of the 14 communities is led by a state Quality Improvement Organization whose job is to refine care delivery systems. The QIOs are: Quality Partners of Rhode Island; IPRO Inc. (in New York); Quality Insights of Pennsylvania; Healthcare Quality Strategies Inc. (in New Jersey); Georgia Medical Care Foundation Inc.; FMQAI (in Florida); AQAF (in Alabama); Health Care Excel (in Indiana); MPRO (in Michigan); CIMRO of Nebraska; Louisiana Health Care Review; Colorado Foundation for Medical Care; TMF Health Quality Institute (in Texas); and Qualis Health (in Washington).
California doctors may soon have to post the state Medical Board's name, Web site, and phone number in their waiting rooms, so their patients know where to complain if they're not happy with care.
Next month, the Medical Board of California will consider requiring any of the state's 125,000 physicians who have waiting areas to "prominently" post a "large, clearly visible sign" 8.5 x 11 inches in 24-point type that says:
Medical doctors are licensed and regulated by the Medical Board of California.
The Medical Board may allow doctors, especially those without waiting rooms, such as radiologists or pathologists, to notify patients in other ways, such as with a brochure or letter that includes similar wording, which could be sent with bills.
California would not be alone with such a posting requirement for doctors. Texas, Kansas, Georgia, and Idaho are among other states that have similar requirements.
"In my experience, many people do not know about the Medical Board of California's existence or enforcement jurisdiction," says attorney Julianne D'Angelo Fellmeth. Fellmeth was appointed by the board as "independent enforcement monitor," a position created by the Legislature, to conduct a two-year examination of the board's oversight process.
When they hear of a physician's alleged misconduct, board investigators first look for court filings. "They routinely come across people who have sued doctors for malpractice but who have not filed a complaint with the Medical Board," says Fellmeth, of the Center for Public Interest Law at the University of San Diego.
A physician's failure to provide proper notice of the board's authority could come with penalties or fines, Fellmeth said.
Medical Board member Mary Lynn Moran, MD, says she is likely to vote for a posting requirement. "If signage is required by cab drivers, it should certainly be expected of physicians to let the public know that they are held to a set of standards and regulated by the state," says the Woodside plastic surgeon. "Consumers have the right to know that if they do not feel that their physician is acting professionally, that the overseeing licensing agency should be informed of their concerns."
The exact language of the board's proposed rule will be issued in several weeks, says board spokeswoman Candis Cohen. Before the rule takes effect, the full board will have to approve it, and then go through a regulatory process of up to six months.
Expectedly, some California doctors are not enthused.
Ted Mazer, MD, a CMA trustee, thinks the regulation "is a stupid waste of time. I think patients already know there's a Medical Board," he said. "Patients will see it, and say 'OK. Whatever.' But I don't think they'll remember that's where they have to go if they have a problem later."
But he also objects because he thinks the posting could encourage patients to report something to the disciplinary agency "that might be far more easily managed with a conversation with the patient."
Mazer, a San Diego ear, nose, and throat specialist, also questioned Fellmeth's motives. "Julie Fellmeth seems to feel that if she doesn't currently have something to slap doctors in the face with, she should find something," he says.
Mazer says he would only support such a requirement if health plans and others who make decisions about patient care as well as attorneys have to post such notices as well, referring patients to the Department of Managed Health Care or the State Bar of California respectively.
James Hay, MD., the CMA's liaison to the Medical Board of California, also thinks the proposed rule is unreasonable.
"The doctor patient relationship from the start should be based on mutual trust," he says. Yet this proposed rule "does not seem to me to be a worthwhile thing to foster that doctor-patient relationship," says Hay, an Encinitas family practitioner. If the Medical Board is supposed to educate the public, but hasn't done it, "that's the medical board's problem," he says. "The Medical Board shouldn't ask the physicians to do it for them." There is enough legal room for such a regulation. A legislatively-mandated report last November by the California Research Bureau noted that a 1998 state law called for the Medical Board to require that doctors notify patients that they practice with oversight from the state. While many other California consumer protection agencies did pass such rules, including those that license architects, auto repair shops, pharmacists, engineers, surveyors, and pest control companies, the Medical Board "has neither adopted nor proposed such regulations," the bureau report said.
That's because of another 10-year-old law, which suggested doctors could satisfy the requirement by wearing a name-tag showing their type of practice and license status. Fellmeth says that view is now discounted. Besides, wearing a nametag still doesn't tell patients that the name of the agency to complain to is the Medical Board.
Fellmeth uses the example of the November 2007 death of rapper Kanye West's mother, Donda, one day after being operated on Los Angeles plastic surgeon Jan Adams.
"If Donda had known about the Medical Board and gone to the board's Web site, she would have seen two medical malpractice judgments of at least $200,000 against Adams. He had been arrested and convicted twice of driving while intoxicated, grounds the medical board was using then in an effort to revoke his license," Fellmeth says. Adams surrendered his license effective April 8.
The CMA currently supports a bill that would require health practitioners to disclose their license type and educational degrees, as well as their board certification. But the CMA bill stops short of requiring any mention that the Medical Board's name, or its phone number be given to patients, Fellmeth says.
"If doctors voluntarily notified patients of the board's existence, we would not need the regulation," Fellmeth says. "But they do not. And it is the law."
When it comes to managing pain, long-term care experts say a proactive approach is best—clinicians should anticipate and treat pain before it becomes too intense. However, it seems that many in the long-term care industry have waited for CMS to dial up the pressure before addressing shortcomings in pain management practices.
But the way nursing homes manage pain is about to come under intense scrutiny with the recent release of new pain management guidance and investigative protocols under the survey deficiency tag F309, Quality of Care. Under the new guidance, which CMS released and implemented April 10, surveyors can cite nursing homes that aren't appropriately managing pain with deficiencies.
In the past, nursing facilities were expected to address and manage pain, but nursing homes and surveyors did not have specific guidelines to do so, says Marilyn Mines, RN, BC, RAC-CT, manager of clinical services for FR&R Healthcare Consulting, Inc. in Deerfield, IL.
"Overall, in the industry, it's been felt that pain has been ignored in the geriatric population, and hence, now we have a [survey] protocol that's extremely complex," Mines says.
The new guidance under F309 states that nursing facilities must assess and address pain in all residents, including the cognitively impaired. To comply with F309, nursing facilities need to reexamine how they assess and manage pain in residents, including the use of pain medications, PRN ("as needed") medication regimens, and complimentary and alternative medicine (CAM).
Assessing and treating pain in cognitively impaired residents, who have difficulty communicating pain through statements or commonly-used pain scales, is a major challenge for nursing facilities.
Nursing homes are most likely to underestimate pain in residents with dementia, says Christie Teigland, PhD, director of health informatics and research for the New York Association of Homes and Services for the Aging (NYAHSA) and EQUIP for Quality in Albany, NY.
Even when residents with Alzheimer's disease and dementia have diagnoses known to cause pain, such as arthritis, neuropathies, and joint disease, their pain is reported only about half as often as in cognitively intact residents with similar diagnoses, according to research Teigland presented to the Alzheimer's Association.
Long-term care experts say some other common shortcomings in many nursing facilities' pain management programs include:
Using PRN medications to treat pain when an around-the-clock regimen would be more appropriate
Prescribing PRN medications for cognitively impaired residents who may be unable to communicate pain or ask for medication
Failing to anticipate pain before pain-inducing activities, such as therapy or wound-dressing changes
Dismissing residents' statements of pain based on personal beliefs or attitudes
The good news for nursing facilities may be that the new guidance simply enforces existing clinical practice standards for pain management rather than introducing new standards.
Facilities that address pain with the "nursing process," which involves assessment, problem identification, care planning, implementation, and evaluating outcomes, should be in compliance with F309, says Rena R. Shephard, MHA, RN, RAC-MT, C-NE, founding chair and executive editor of the American Association of Nurse Assessment Coordinators and president of RRS Consulting Services in San Diego.
"Facilities that have been doing this well aren't going to find anything surprising, and they don't have anything to worry about," Shephard says.
As Joint Commission citations increase for Life Safety Code® (LSC) violations, many of you are becoming more aware of these problems. A further twist may put this concern in an even brighter spotlight.
The Joint Commission's life safety specialists review LSC compliance during all hospital surveys. While the specialists concentrate on five physical environment standards during their intensive, day-long reviews, they can also look for related compliance in a trio of Joint Commission leadership (LD) standards.
The LSC sets a variety of fire protection provisions for hospitals and other healthcare facilities. The National Fire Protection Association in Quincy, MA, publishes the LSC; however, it is up to authorities such as The Joint Commission to enforce the code.
The relevant LD standards and specific elements of performance (EP) to watch for include:
LD.04.01.05, EP 4, which requires hospital leaders to hold staff members accountable for their responsibilities
LD.04.01.11, EP 5, which mandates that leaders provide for adequate equipment and resources
LD.04.04.01, EP 2, which requires leaders to give priority to problematic processes for the purposes of performance improvement
HealthLeaders Media caught wind of a recent example of one of these LD standards in action. During a review of fire protection equipment documentation at one hospital, a life safety specialist said a contractor had not completely tested all of a protection system's components.
As a result, the surveyor issued a citation under LD.04.01.05, EP 4, because the hospital worker assigned to monitor the contract did not adequately review the report to verify system components were properly documented, according to a former surveyor who spoke on condition of anonymity.
Typically, fire protection equipment inspection, testing, and maintenance falls under a Joint Commission environment of care standard, but in this case the life safety specialist believed the crux of the problem resided with leadership's oversight.
The issue of vendor contracts is on the radar of George Mills, FASHE, CEM, CHFM, senior engineer at The Joint Commission. Mills oversees interpretation and enforcement of life safety requirements for the commission.
At the 2008 annual conference of the American Society for Healthcare Engineering in National Harbor, MD, Mills told attendees that he was frustrated by hospital managers who blame vendors for not having fire equipment testing results available for surveyors.
In such cases, it is up to facilities to monitor vendor performance, and a lack of such diligence points to a problem with a hospital's leadership style, he added.
Other life safety deficiencies that might lead to an LD standard citation include unrealistic completion dates for projects and administrators pulling back budgets for improvement plans previously approved by The Joint Commission.
The Joint Commission introduced its life safety specialists to survey teams in January 2005 following a U.S. Government Accountability Report that concluded Medicare validation surveys at hospitals uncovered serious fire safety deficiencies that Joint Commission surveyors hadn't identified in earlier visits. The Joint Commission has deeming authority to accredit hospitals as being compliant with the Centers for Medicare and Medicaid's Conditions of Participation.
As the ongoing debate flushes out the details about what healthcare reform will look like and how much it will cost, Congress and the Obama administration are expected to re-examine the idea of taxing employer-sponsored healthcare benefits. The Congressional Budget Office estimates the value of the tax-exempt status of employer-sponsored health insurance and other medical spending at about $246 billion annually.
Bill Roper, MD, CEO of UNC Health Care System in Chapel Hill, and the administrator of the Health Care Finance Administration (now CMS) under President Bill Clinton, has long advocated taxing health benefits, even though people "recoil" at the idea.
"The way I would do it is to say we will impose a limit on the tax-free treatment of health benefits," Roper says. "For more generous plans, whatever that level turns out to be, those benefits will be taxed as ordinary income. That will produce at least some revenue. How much depends on the level that the tax cap is imposed."
Roper believes that will create a "dramatic incentive" to change the design of health benefits plans below the tax to make them more cost-effective than they are now. "That is something we badly need to have done to drive down the cost of care," he says.
"Otherwise the only way we can control the cost of this stupendously expensive healthcare system is to control the cost of the system—some sort of government mandate that says, 'You can't have X or Y.' I would much rather have a system that says if you want to have tax-free health insurance from your employer, it needs to be a plan design that has built-in cost-containment features."
Karen Greenrose, president and CEO of the American Association of PPOs, says her organization doesn't necessarily oppose what Roper is saying. However, she believes that all stakeholders in the debate must first determine at what level health insurance is a right and when, if ever, it is a privilege. "We would all benefit much better if we had that discussion, and then you overlay some of the ideas like Dr. Roper's," Greenrose says.
Greenrose says the nation's healthcare safety net should be expanded before anyone starts talking about an overhaul. "We would go a long way toward lowering the cost if we did that instead of just saying 'let's throw everything out that needs to be overhauled,'" she says. "Right now, the discussion is 'the system is broken. Let's fix it. It needs to be overhauled. Now we are going to tax it. We're going to put some money out for HIT.' We are all over the place, not only as an industry, but all the players and stakeholders who are talking about healthcare reform. We haven't started at the beginning and worked our way through."
Helen Darling, president of the National Business Group on Health, says employers are leery about taxing healthcare benefits because it will be seen by employees as a take away. "Employers are worried that they will be expected to compensate for that at a time when that would be very hard. Plus, they would prefer not to do it," Darling says. "A cap that is set high enough that it doesn't really catch anybody right away so there is time for transition is very different from taxing the whole thing."
A tax cap could prove problematic in areas of the nation where healthcare costs are generally higher, such as the Northeast. "The details really matter a lot," she says.
John Holahan, director of the Health Policy Center at the Urban Institute, says that tax-free health benefits disproportionately favor wealthier Americans and encourage waste in the healthcare system. He supports levying a tax on benefits, but agrees with Darling that setting the cap at the correct level is critical. "They shouldn't be fully taxed. To totally eliminate the exemption and try to replace it with something else and move 170 million or so people who benefit from that into something else that doesn't exist at this point is just nuts," he says. "Cap it so that at the highest levels it's treated as taxable income above a certain dollar amount for singles and families. That would be way less disruptive to the current system and provide revenues that would help pay for healthcare reform."
Opponents and supporters of taxing healthcare benefits say they are left with few options because of the high costs of reforms and the increasing difficulty in accessing healthcare services. "If the larger goal is to get everyone covered, then people will have to give on something they might not otherwise support," Holahan says. "I'd try to set the cap at a level at which the people who would defend it would have a fairly weak argument." Given that the country is in desperate straits, Darling says nothing in the healthcare reform debate is off the table. "There is not even an idea of a line in the sand in this day and age," she says. "We just have to be realistic about the future."
Michael Mack, MD, a surgeon on the medical staff of The Heart Hospital Baylor Plano and medical director of cardiovascular surgery for Baylor Health Care System,has been named president-elect of the Society of Thoracic Surgeons. In this role, Mack will provide leadership for the more than 5,600 surgeons, researchers, and allied health professionals worldwide who are members of the Society.
Steve Schelhammer, CEO of Phytel, which develops medical home technology, has joined the Executive Committee of the Patient-Centered Primary Care Collaborative. The PCPCC is a collaboration of employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians, and others that have joined together to develop and advance the patient-centered medical home.
