Without sufficient skills, first-line managers do not benefit an organization. The first step to increase the number and education of managers is to provide effective training designed to specifically improve organizational performance.
Google Health and others in the fast-growing personal health record business say they are offering a revolutionary tool to help patients navigate a fragmented healthcare system. Some doctors, however, fear that inaccurate information from billing data could lead to improper treatment.
Accreditation professionals across the country have known for months that revisions to Joint Commission standards will go into effect on July 1. One unanswered question has stood out among others, however: how will hospitals be scored on the various changes The Joint Commission has announced?
Now we have an answer. The Joint Commission has released scoring guidelines for the current list of revisions the accrediting body is expected to implement on July 1.
Four days after The Joint Commission's 2009 standards went into effect, the organization released an update intended to help bring existing standards in line with the Centers for Medicare & Medicaid Services Conditions of Participation. Since that time, the field has seen the release of a second update with proposed revisions to the standards, cutting the number of revisions in half.
The Joint Commission is currently undergoing the application process for continued deeming authority with CMS. These latest revisions came about following discussions with CMS where certain new or revised standards were found to be covered elsewhere in the standards and thus unneeded.
"Discussions with CMS are a routine part of the deeming application process," says Elizabeth Zhani, media relations specialist with The Joint Commission.
Can we expect any further changes before the July 1 implementation date?
"The Joint Commission submitted its deeming application to CMS in March," says Zhani. "Throughout the deeming application process The Joint Commission will continue to work with CMS. It is difficult to predict if there will be additional changes based on these discussions."
Experts in the field note that this latest round of information will help to identify which standards will have the greater bearing on potential adverse decisions following a Joint Commission survey.
"It looks like they've made some of the more frequently cited issues—Histories and Physicals, timing and dating of orders, authentication of verbal orders—non-direct impact level Elements of Performance, which technically means these should not roll up into any adverse decision Requirements for Improvement (RFI) for the hospital," says Lisa Eddy, RN, CPQH, CSHA, senior consultant with The Greeley Company, a division of HCPro, Inc.
Eddy notes that the standard listing what The Joint Commission requires included in the medical record is a direct impact standard (Level 3)—which means if, for example, allergies are not listed in the medical record the hospital can be hit with a Level 3 RFI. Pre- and post-anesthesia assessment and evaluation suffer a similar challenge, Level 3 direct impact standards which would count towards the total number of RFIs, which could lead towards an adverse action directed at the hospital's accreditation.
"The restraint Elements of Performance dealing with use of restraint only for appropriate reasons have the direct Level 3 impact category attached, as does ordering of restraints," says Eddy. "However, many other [standards] that tend to get facilities into trouble do not."
Crosswalks between the various rounds of revisions and additional supporting documents can be found on Joint Commission Web site.
In one corner stands the powerful California Hospital Association, poised for a knockdown fight to pass a law allowing medical centers to employ physicians, specifically in rural areas where doctors are in short supply. Three recently introduced state bills would permit this practice to varying extents.
In the opposing corner stands the influential California Medical Association which is resolved to block any such change.
"These are some of our highest priority bills to oppose this year," said Brett Michelin, CMA lobbyist. California needs to "ensure that a physician's loyalty is to the patient first and foremost," not to hospital administrators, he said. "We're fully expecting to kill (these bills) if we can."
But CHA spokeswoman Jan Emerson remarked: "California is the only state in the country that has a flat out ban" on hospital employment of doctors. While four other states—Ohio, Iowa, Texas, and Colorado—have similar prohibitions, they are not as well enforced as California's, she said. "There's no question that getting this legislation passed is a top priority for us this year. The current policy is a relic from decades past."
The CMA says it is flexing its political muscle to resist this change out of fear that if hospital administrators can hire physicians, they also will tell them which patients to admit and what tests to order based on the need to fill beds and payment expectations rather than medical need. Even though the bills restrict such influence, underinsured and Medicaid patients could get poorer care, says the CMA. The CMA also believes that those same hospitals will refer well-insured patients to their own doctor employees rather than to competitors in the community. "The hospital will dominate the market," Michelin said.
James Rohack, MD, president-elect of the American Medical Association, said: "The physician would be put into a very difficult situation of being forced to admit a patient who doesn't need to be, or to not admit a patient who does because the hospital would lose money." Asked whether his physician association has tried to fight policies in other states that allow hospitals to hire physicians, Rohack said the AMA only jumps in if requested by a state's medical association. That hasn't happened in recent memory, he said.
Currently in California, institutional hiring of doctors is limited mainly to teaching and county hospitals and prisons. Other hospitals contract with physician groups, according to state requirements.
But Tom Petersen a director with the Association of California Healthcare Districts, says such a law is desperately needed to stop the rapidly declining supply of doctors willing to practice in inner city, rural, or district hospitals—from Fall River near the Oregon state line to El Centro near the Mexican border. "Doctors can't make a living seeing only Medi-Cal (Medicaid) patients and still save for the kid's college tuition," he said.
"When the CMA says you can't have doctors working for non-doctors because it's not safe, the question comes up: What does that say about our teaching and county hospitals (which can hire physicians)?" he asked. "If this is a quality issue in California, then it ought to be a quality issue in Florida, Mississippi, and New York. But it isn't."
Besides, he said, today's younger doctors have different life expectations than older practitioners.
"Younger doctors want to make a good living, with a defined number of hours, minimal stress, with benefits and a pension. They don't want to have to hire, fire, or counsel their staffs," Petersen said.
Areas defined as "rural" make up 75% of the California's geography, have high numbers of underinsured, but have 30% fewer physicians and surgeons than metropolitan Los Angeles or the San Francisco Bay Area, hospital officials argued.
In 2003, a narrow pilot program attempted to address the issue by allowing 69 rural hospitals with significant numbers of uninsured, Medicare or Medicaid patients to hire up to two physicians, but no more than 20 statewide.
But only five hospitals took advantage of that pilot, hiring only six physicians, according to a report last fall by the Medical Board of California. Raymond Hino, CEO of 25-bed Mendocino Coast District Hospital, was able to hire a needed oncologist, but the candidates for another position for a hospitalist preferred other states where they would get employment benefits. Mendocino draws from an 80-mile, winding stretch of the North Coast, from Westport to Sea Ranch, and it badly needs more physicians, Hino said.
That cancer specialist, John Rochat, MD, now operates his clinic within the hospital, providing care such as infusions to hundreds of coastal patients who otherwise would have to drive two or three hours each way to Santa Rosa or the Bay Area to get their treatments.
Rochat's contract expires next year. Without legislative remedy, he said, he will have to move to another state where he can be hired by a hospital. He can't afford to set up his own office and front the cost of expensive chemotherapy. "We could also use a cardiologist or pulmonologist here, but that's not going to happen" unless the law is changed, Rochat said.
Rochat said it's ridiculous for the CMA to suggest his hospital's administrators tell him how to practice. Insurance companies "all tell you how to practice medicine in one form or another. Do our CEOs tell us how to practice? Not at all. They wouldn't know how to begin."
For sure, CMA and CHA are poised for battle in an ugly legislative contest. But there is one way to soften the blows. Both sides acknowledge severe doctor shortages. If the pilot is revived and expanded, perhaps with subsidies, inner city and rural hospitals and their patients may get a solution satisfying for all.
With a serious expanded pilot, agencies such as the Medical Board of California can act on its recommendation last fall to really examine whether the practice improves patient access without compromising anyone's medical practice integrity.
There has been a recent departure from years past when the U.S. health industry's rapid growth outpaced the number of nurses entering the field. As of last summer, the nation had a shortage of roughly 125,000 nurses, based on vacancies at hospitals and in long-term care. That is still expected to balloon to 300,000 to more than one million nursing vacancies by 2020. But because of the recession, the nursing shortage appears to be waning, at least temporarily.
Employment in healthcare, the only major industry outside the federal government still adding jobs, is succumbing to the recession. In the latest sign, the president of New York City Health & Hospitals Corp. wrote to community organizations as well as employees and unions at its 11 hospitals and four nursing homes, saying the agency will lay off more workers even after slashing 400 jobs last month. More than 16 million people work in healthcare today, up from just 1% of the work force 50 years ago.
While most physicians and hospitals are familiar with acronyms such as HMO or PHO, many might be stymied by one of the newer one under discussion in Washington: ACO—or accountable care organization. Unlike healthcare maintenance organizations or physician hospital organizations, ACOs don't exist yet, but they are attracting attention as a possible way to lower Medicare costs and volume by rewarding providers that promote quality healthcare for specific groups of patients.
At the meeting of the Medicare Payment Advisory Commission(MedPAC) last week in Washington, DC, Chairman Glenn Hackbarth noted "there's a lot of interest in this idea in Congress." Overall, he said that better organized delivery of care is seen as "an important step in improving the healthcare system."
While MedPAC, which advises Congress on Medicare issues, will not be making formal recommendations about ACOs this year, Hackbarth said it still was important to get a concrete discussion about ACOs on the table and into the report it delivers to Congress in June.
MedPAC staffer David Glass said at the meeting that ACOs can include a variety of hospitals, primary care physicians, and possibly specialists. Potential ACOs could be made up of integrated delivery systems, PHOs, hospitals with multispecialty groups, or even academic centers.
However, ACOs would work to promote improved "care coordination and collaboration with providers," Glass said. Working with a defined group of Medicare patients, "the hope would be that unnecessary services would be reduced and quality would be improved."
In turn, provider payments or bonuses would be tied to quality and resource use. Quality benchmarks, for instance, could include objectives such as lower mortality rates or hospital readmissions.
In the long run, eliminating unnecessary care by controlling volume would be preferable to using the "blunt tool" of reduced fee-for-service rates, Glass said. "The motivation [of ACOs] is to find the way to slow the growth in Medicare spending."
What needs further discussion is whether a voluntary or a mandatory model would work. With a volunteer model, providers could be assigned to an ACO, while with a mandatory model, the Centers for Medicare and Medicaid Services could assign providers to a virtual ACO.
In addition, decisions would have to be made on whether CMS assigns particular patients to a network based on claims, whether patients would be locked into a provider network, or what type of rewards (bonuses, withholds, or both) would be considered. Also, combining ACOs with existing models, such as Medicare Select, to promote lower beneficiary premiums (in return for cost savings) could be considered.
Hackbarth, receiving agreement from the other commissioners, noted that ACOs probably should be voluntary and flexible—"coupled with a restraint on traditional Medicare." But in the long term, the private sector would need to consider the impact of using ACOs as well to save costs and promote quality. "I believe that ultimately the success [of using an ACO model] will hinge on private payers moving in the same direction."
Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached atjsimmons@healthleadersmedia.com.
If you've read the American Recovery and Reinvestment Act (ARRA) of 2009, you know that the money is in EHRs. But are hospitals really focused on implementation these days, and what are some of the major barriers?
A quick Google search for this information reveals a barrage of articles, many of which yield somewhat conflicting statistics. Consider the March 25 online report published by the New England Journal of Medicine that indicates hospitals are definitely behind the eight ball when it comes to EHRs. Only 1.5% of the 3,049 U.S. hospitals surveyed had a comprehensive system (i.e., it includes hospital-wide clinical documentation of cases, test results, prescription and test ordering, plus support for decision-making that includes treatment guidelines).
"This is mostly because physicians are resistant to adopt EHR technology that changes their work patterns," says Kelly McLendon, RHIA, president of Health Information Xperts, LLC, in Titusville, FL.
"The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care performance goals that depend on health information technology," states the report.
Of the 304 respondents—many of whom responded prior to President Obama's February 17 signing of ARRA—31% said the primary focus would be ensuring their organization has a full EMR. Seventeen percent said the primary focus would be the installation of a CPOE. To assess the impact that the ARRA will have on HIT spending, HIMSS is gathering additional information from survey respondents, according to the press release.
At NorthShore University HealthSystem in Evanston, IL, EHR adoption and CPOE have been top priorities since 2001 when the system began its implementation process. Physicians were on board with the technology because they were simply told "this is the way we were going to be doing business," says Terri Bunsen, chief privacy officer for the four-hospital and 70 plus physician office health system.
NorthShore is one of two recipients of the HIMSS Stage 7 award that recognizes hospitals for achieving a paperless advanced patient record environment. The award is part of a larger EMR adoption model that HIMSS Analytics uses to track the progression of hospital EMR adoption nationwide.
ARRA specifically references physician order entry and clinical decision support as prerequisites, although the specifics of these requirements remain unknown. And there may continue to be a big question mark until December 31—the date by which the HHS Secretary will adopt an initial set of standards, implementation specifics, and certification criteria.
The available incentives should definitely help to spark widespread adoption, McLendon says, although he admits that CPOE may be the most challenging aspect of implementation. "It [ARRA] gives hospitals millions of dollars worth of reasons to procure good EHR software and mandate adoption," he says. "But the hospital has to have the political will to mandate full use of CPOE and other decision-support tools across the entire clinical and medical staff."
Lisa Eramo, CPC is a senior managing editor in the health information management division of HCPro, Inc.She is located in Rhode Island and writes content for the company's flagship newsletter, Medical Records Briefing. Contact her atleramo@hcpro.com.
The annual J.D. Power and Associates' National Health Insurance Plan Study is a chance for highly-ranked health plans to puff out their chests, but this year's results highlight more than the fact that New Englanders are happier with their health insurance than other regions and Kaiser Permanente ranked number one in four geographic areas. For the health plan executive, there is also this nugget:
Health plan members care most about coverage, benefits, and provider choice, but members' knowledge about their plans underlies all of those issues.
The third annual survey measured member satisfaction for about 33,000 Americans enrolled in 131 health plans in 17 regions by examining seven factors: coverage and benefits; provider choice; information and communication; claims processing; statements; customer service; and approval process.
Member experience is one of those difficult-to-define topics that financial experts have a tough time gauging, but the survey found that member knowledge plays a critical role in whether an individual is satisfied with his or her plan and taking advantage of offerings, such as preventive services. Members who don't understand their plans are more costly and more apt to call the health plan to ask basic questions.
In other words, positive member experience and plan knowledge have a direct correlation to costs.
"If the member understands the plan very well, they understand what's covered and what's not, and understand how to use those services," says David Stefan, executive director, healthcare, J.D. Power and Associates in Phoenix, AZ.
The survey also found that health plan members in small group and individual plans were less satisfied with their insurer than those who worked for large businesses (501-5,000 employees) and jumbo employers (more than 5,000 employees). Those who worked for large employers were more likely to re-enroll and recommend the plans to others than people who were employed by small employers or were enrolled in individual plans.
Individual health insurance has become one of the few areas of growth for health insurers in recent years as more Americans turn to individual plans because they lost their employer-based coverage. Nine percent of health plan members are enrolled in individual plans and that figure is expected to grow.
Though individual plan members are less satisfied than those in large group plans, member knowledge is a problem throughout the healthcare system. Americans simply don't understand their health plan coverage. In fact, the study showed that close to two-thirds of surveyed members were confused about how their plans work to one degree or another.
"We see a very big difference between people who say they fully understand how it works and those who have some level of confusion," says Stefan, who adds this finding shows the need for better new member communication.
Kaiser Permanente, which was one of the highest rated health plans in the J.D. Power and Associates survey, performs new member outreach that features an introductory phone call that explains offerings and benefits, and promotes the importance of forging a strong relationship with a primary care physician.
As an integrated healthcare system, Kaiser Permanente has an advantage over companies that are strictly health insurers. Having hospitals and doctors under the same umbrella as a health plan allows the Oakland, CA-based company to communicate with its member on care delivery and not just answer questions about coverage. This leads to members viewing their health plan as connected to their doctors rather than as a separate claims-paying entity.
"We tend to see the experience of the care driving the satisfaction rather than the experience of the coverage per se," says Christine Paige, senior vice president for marketing and Internet services for Kaiser Permanente. "We're very focused on connecting people with the services and making sure they have good access to [Kaiser programs], and those in turn drive satisfaction."
Paige says insurers are finding that they need to communicate with members about issues beyond urgent care or claims processing.
"I think one thing you are seeing more and more of is a focus on communicating with people about not just how to access care when you're ill, but more about prevention and wellness," says Paige.
New federal HIPAA laws are here. Anxiety at hospitals is not.
That wasn’t the case in 2003, when providers scrambled for answers to comply with the new privacy and security rules of HIPAA.
Then, many even had trouble even getting the acronym right (admit it, we’ve all written "HIPPA" at one time or another).
Here we are today, six years later, and with a Congress eager to move the industry to EHRs by 2014—and even more eager to protect patients’ privacy in the process.
Now that Congress (finally) strengthened HIPAA enforcement and toughened compliance requirements through breach notification processes and accounting of disclosures on EHRs, what’s the reaction in the industry?
Well, picture this. It’s kind of like the Boston Celtics just signed Larry Bird. Not Larry Bird, the NBA Hall of Famer, three-time NBA champion and three-time NBA Most Valuable Player of the 1980s.
We’re talking about Larry Bird today—the 52-year-old, out-of-shape president of Basketball Operations for the Indiana Pacers.
If you’re the rest of the league, you’re not really sweating it.
Analysis: HITECH Gives HIPAA New Teeth
HITECH Act will impose stricter HIPAA requirements and stiffer penalties for violations. But at this point, the changes aren't worth losing a lot of sleep over. —Elyas Bakhtiari
"I'm afraid that at this time we are not moving too quickly with any changes in our practices," one privacy officer told us. "The corporate direction we have been given does not have us moving immediately to revise applicable policies/procedures. As we both know, once a bill is signed there are timetables by which compliance will be required and that, generally, allows organizations sufficient time to bring their practices up-to-date. We are, merely, digesting all the material that is coming out with respect to this Act."
That’s the Cliff’s Notes version of our research at this point. The key phrase here is reluctance—not ignorance.
Hospitals certainly plan to do something in light of security provisions in the HITECH Act. In fact, 98% of respondents in our HITECH survey of 300 privacy and security officers said they plan to revisit their HIPAA compliance and training programs.
"One thing I do see is people taking their policies off the shelf and revisiting them to see how they will need to be amended to accommodate those requirements and definitions which are soon to be established by those governmental entities as identified within the HITECH Act," says Frank Ruelas, MBA, the creator of www.hipaabootcamp.com who is based out of Scottsdale, AZ. "Sometimes it takes an event such as the passage of new legislation to serve as the tipping point to get folks to take action."
So why the reluctance now?
Our feedback tells us hospitals don’t want to move too much with regulations that have yet to be defined. And there are a host of them, including:
The definition of "unsecured protected health information"
What must be included in an accounting of disclosures in EHRs
When the Secretary of HHS will conduct audits of organizations
What "meaningful user" means on EHR
And in a shocker, hospitals said they just can’t invest money right now.
Furthermore, some providers told us they’re more worried about the Red Flags Rule deadline—May 1. Hospitals considered to be creditors must set up a policy and procedure that helps them identify "red flags" on identity theft, prevents them and corrects them through self-audits (the FTC last week came out with some nice guidance to help comply).
So where is your organization on the HITECH Act? Is the panic button a 2 or 3, or is it up to a 9 or even a 10?
If you’re like most of the industry it’s probably the former. And essentially, those hospitals with a strong HIPAA compliance and training program in place should be fine with the new regs. If you are confident your facility won’t have a breach, then you need not worry about federal auditors or breach notification requirements.
But for those who don’t have a policy in place—and perhaps those who have suffered a breach of privacy at one point (see: CVS)—then, well, maybe your panic level should be a 10.
Because after all, federal law is federal law. Just like Larry Bird is Larry Bird.
