Many hospital and freestanding breast disease programs around the country are scurrying to qualify for the National Accreditation Program for Breast Centers, a new survey validation that began Jan. 1.
So far, says David P. Winchester, MD, chairman of the program's board, only 125 hospitals nationally in 30 states have been accredited, but another 150 are in the last stages of the application process, which is administered by the American College of Surgeons. About 1,200 have sent inquiries.
The effort to develop an accreditation program for breast disease care began because, with 250,000 patients diagnosed annually with breast disease—190,000 with invasive and 60,000 with non-invasive disease—"there is such a major public health problem, and there has been a proliferation of 'breast centers' around the country in the last decade" Winchester says. Yet there was no organization or effort to establish evidence-based care criteria, visit the centers, and give guidance for improving quality, he says.
"Here we are with an unknown number of breast cancer centers in the country, probably about 1,500, yet nobody could answer the question about whether there is a problem with quality," Winchester says. No one knew which centers embraced "widely accepted evidence-based standards," and which ones perhaps fell short.
"The old system was very fragmented, involved several individuals offering their own opinions of different types of care, even in our own geographic area," says William Dugoni , MD, medical director of Washington Hospital's women's health program, the latest to receive accreditation. "What we've done is standardize and we've given patients opportunities to have equal access, and to have their cases discussed by a multidisciplinary team."
The only other accreditation agency that looks at cancer care quality, Winchester says, is the Commission on Cancer, an 80-year-old program that reviews 36 standards for cancer care, but doesn't focus on or specialize in any one. It certainly does not look at breast care with nearly the detail, says Winchester, who also is the Commission on Cancer's medical director.
The new NAPBC program requires that each designated breast center provide 17 components of care: an interdisciplinary conference to discuss a patient's disease treatment, data management, patient navigator, survivorship program, pathology, imaging, needle biopsy (core preferred) surgical care, and radiation oncology consultation and treatment. It also looks at medical oncology consultation and treatment, nursing, genetic evaluation and management, education, support and rehabilitation, plastic surgery consultation and treatment, research, outreach and education, and quality improvement.
The NAPBC requires 27 program standards or components, which set forth organizational, responsibility and accountability criteria, require multidisciplinary patient management, a standardized breast cancer staging, imaging, pathology, and biopsy criteria. At least half of all patients diagnosed with early-stage breast cancer must be offered or treated with breast conserving surgery.
And the centers must have a clinical trial component that promotes prevention, early diagnosis, and treatment.
The programs must also have breast cancer surveillance for following patients. Winchester says the NAPBC will actually monitor care. "Let's say Mrs. Smith had a lumpectomy eight months ago, with positive nodes, and was premenopausal, and didn't get chemotherapy. We know that. We fire back a report to the center saying, 'Why not?'"
"We'll survey another three years, with an audit on site, and make sure nobody slips through the cracks. And so far it's working. We feel like we're raising the bar."
Very few if any of the centers are fully compliant during their first pass at the application process, Winchester says. "We've observed in a very consistent manner that it's taking breast centers anywhere from three to six months to complete the SAR (the online survey application record)," a key component in the process.
The biggest problems are inadequate patient navigation programs and problems with radiologist and surgeon skill certification for performing certain breast specific procedures, such as imaging-guide breast biopsies, Winchester says. "If we'd gone out with these first 125 and found that everyone was perfect, there would be no reason for this program," he says.
There is no requirement for number of breast cancer cases the center must treat each year. The NAPBC charges the center $3,500 to $4,000 for the survey process, which, similar to the Joint Commission, will be up for renewal every three years.
The accreditation, however, does not make the breast center eligible for federal reimbursements or health plan contracts, but that may come in time.
One system that was among the earliest adopters is Washington Hospital in Fremont, CA, 37 miles southeast of San Francisco. Washington recently become the only west coast hospital between Seattle and San Diego to be accredited, primarily because Washington's breast care program was so far along when the concept was launched, says Winchester and Dugoni.
"Overall, it's led to a much better quality of care, and allowed us to monitor the outcomes of disease," says Dugoni.
Dugoni says that one benefit from having such a program—and Washington's is all under one roof—is how the streamlining care has reduced time to diagnosis. "We've taken it from 35 days to under 14 days, and that's with all the limitations of insurance."
Winchester and Dugoni agree that hospitals may want to consider marketing this accreditation, and many already are. "In this tough economic time, when you sell yourself as a national accredited center of excellence, you pass a rigorous set of standards, that should indicate this is a very good place for me to be treated," Dugoni says.
"But," he quickly adds, "whether this is used as a marketing tool or not, there's a recognition that we have put together a program that make sure everything is vigorously followed, pursued through science and with patient education and that the outcome is the very best possible one for women."
So far, only four states have more than five designated centers: Pennsylvania, 13; Virginia and Wisconsin, 11 each; and North Carolina, 8.
Businesses and individual donors hit hard by the recession have shifted charitable giving patterns to longer-term pledges and gift commitments rather than ceasing to give altogether, according to a study released today by the Association for Healthcare Philanthropy.
"The fact that in this deep recession, donors are still givers and have not halted contributions signals a depth of relationship and commitment to the individual organizations, which should be continually nurtured by healthcare fundraising operations," said William C. McGinly, AHP's president/CEO, in a media release. "The real message here for healthcare executives and boards is take care of your donors and support your fundraising staff and mix of fundraising activities to cope with the recession."
The fourth annual AHP study of benchmarking data and philanthropic fundraising techniques found that the most effective fundraisers use a variety of well-rounded programs and activities to raise money, shattering the myth that big-ticket galas, golf tournaments, and telethons are the only way to attract donors, McGinly said. The study found that the most successful philanthropic programs emphasize building relationships and cultivating major gift donors.
Data were gathered from 58 foundations that support nonprofit hospitals across the U.S. and Canada, focusing on the 2008 fiscal year when the recession's full impact was hitting charities hard.
The data was compiled through AHP's Performance Benchmarking Service. Participating organizations compare their fundraising programs and results against those of industry leaders to upgrade business practices, achieve fundraising goals, and integrate philanthropy into their healthcare organization's strategic plans. Using data collected from participants, members generate comparison reports for improved financial and human resource evaluation and planning in language CEOs and CFOs understand.
The nonprofit AHP's more than 4,500 members direct philanthropic programs for 2,200 nonprofit healthcare providers in North America. To view the report, e-mail: ahp@ahp.org.
HHS is providing $60 million in grants for researchers to develop so-called Strategic Health IT Advanced Research Projects to target "breakthrough advances" that overcome barriers to the adoption and meaningful use of health IT.
"Innovative research and approaches are required to overcome some of the foremost challenges we face in achieving our vision of a transformed healthcare system enabled through health IT," said David Blumenthal, MD, HHS' National Coordinator for Health Information Technology.
"The SHARP program will bring together some of the best and brightest minds in the nation to find breakthrough solutions and innovations that will eliminate barriers to adoption and, over time, increase the meaningful use of health IT to improve the health and care of all Americans," Blumenthal said.
Funding for the four-year research period will target:
Security of health IT research to develop security and risk mitigation policies and the technologies to build and preserve the public trust as health IT systems become ubiquitous.
Patient-centered cognitive support research to align health IT with the day-to-day practice of clinicians as they provide care.
Healthcare application and network platform architectures research to achieve electronic exchange and use of health IT securely, privately, and accurately.
Secondary use of electronic health record data research to improve the overall quality of healthcare, population health, and clinical research, while protecting patient privacy.
Each project will create a research agenda addressing the specific goals of the Health Information Technology for Economic and Clinical Health Act and identify the barriers to adoption and meaningful use of heath IT. HHS expects to award qualified applicants cooperative agreements to support research efforts in these four project areas.
The researchers will implement a collaborative, interdisciplinary program addressing short-term and long-term challenges in their focus area. Additionally, the projects will develop and implement a cooperative program between researchers, healthcare providers, and other health IT sector stakeholders to incorporate results into health IT practices and products.
The funding is authorized under the $787 billion American Recovery and Reinvestment Act. Applications are due January 25, with awards anticipated in March 2010. Information about the SHARP program can be found at http://HealthIT.HHS.gov/ and at www.grants.gov.
The Congressional Budget Office (CBO), in its newest estimates on the Senate healthcare reform bill released on Saturday, said that gross cost would be roughly $23 billion higher ($871 billion) over the next 10 years with the new manager's amendments, compared to the $848 billion attached to the original bill presented last month.
The changes with the largest budgetary effects include:
Replacing the insurance public plan option with "multi state plans" that would be offered under contract with the Office of Personnel Management.
Expanding eligibility for a small business tax credit.
Deleting provisions that would increase payment rates for physicians under Medicare.
Increasing the payroll tax on higher income individuals and families.
Meanwhile, the payroll tax rate for individuals with income above $200,000 and for families with income above $250,000 was raised from 0.5% to 0.9%. This provision would account for a large proportion of the $26 billion increase in federal revenues over the next decade, CBO said.
Beginning in 2013, insurance policies with high total premiums would be subject to a 40% excise tax on the amount by which the premiums exceeded a specified threshold—set initially at $8,500 for single policies and $23,000 for family policies (with exceptions). The excise tax on these plans would generate about $35 billion in additional revenues in 2019, CBO said.
CBO projected a net cost of $614 billion over 10 years for the proposed expansions in insurance coverage. That net cost itself reflects a gross total of $871 billion in subsidies provided through the exchanges, increased net outlays for Medicaid and the Children's Health Insurance Program (CHIP), and tax credits for small employers. Those costs will be partly offset by $149 billion in revenues from the excise tax on high premium or "Cadillac" insurance plans and $108 billion in net savings from other sources.
By 2019, CBO estimates, the number of nonelderly people who are uninsured would be reduced by about 31 million—leaving about 23 million nonelderly residents uninsured. A third of that number would be unauthorized immigrants.
Approximately 26 million people would purchase their own coverage through the new insurance exchanges, CBO said, and roughly 15 million more enrollees in Medicaid and CHIP than is projected under current law. The number of people obtaining coverage through their employer would be about 4 million lower in 2019 under the legislation.
In a separate addendum and correction completed Sunday, CBO said that it expected Medicare spending under the bill to increase at an average annual rate of roughly 6% during the next two decades—well below the roughly 8% annual growth rate of the past two decades.
As the Senate heads for a potentially eventful week of debate and votes on health reform, a number of healthcare organizations are stepping forward with their support and opposition to the plan.
In a letter to Sen. Harry Reid, Rich Umbdenstock, president and CEO of the American Hospital Association, said it strongly supports the bill's "approach to increasing competition in the insurance market and providing more choices to patients, utilizing non-governmental, nonprofit entities to provide coverage, and rejecting a further expansion of public programs that do not compensate adequately for the cost of care."
The AHA also supports "meaningful delivery system reforms" such as bundling of physician, hospital, and post acute services, and allowing hospitals to take a leadership role in accountable care organizations, said Umbdenstock.
However, Umbdenstock added AHA has concerns about cutting payments to Medicare and Medicaid disproportionate share hospital programs and the Medicare hospital update. In addition, "policy and reductions related to hospital readmissions are problematic, and may penalize hospitals for readmissions that are unavoidable."
Chip Kahn, president of the Federation of American Hospitals (FAH), said that FAH was "particularly pleased" that the bill "as amended, would increase access to affordable, quality coverage; create market based exchanges with private coverage and subsidies for lower income Americans; and implement important delivery reforms such as value based purchasing, a prospective ban on self referral to physician owned hospitals, and voluntary pilots to test bundled payments across an episode of care."
However, he noted, the bill as amended would "benefit from further improvements in several important areas", including covering more uninsured Americans [the current predicted rate is 94%]. Also, the hospital readmissions policy "falls short by not sufficiently focusing on those readmissions that are preventable and avoidable," he said.
The American Medical Association (AMA) also announced its support for passage of the amended Senate health system reform bill, which it said would "bring our nation close to the finish line on health system reform."
The AMA said the bill would improve choice and access to affordable health insurance coverage and eliminate denials based on pre-existing conditions as well as increase coverage for preventive and wellness care.
"All Americans deserve affordable, high-quality health coverage so they can get the medical care they need—and this bill advances many of our priority issues for achieving the vision of a health system that works for patients and physicians," said AMA President-elect Cecil B. Wilson, M.D.
Though the AMA spoke positively of the bill increasing payments to primary care physicians and general surgeons in underserved areas, the organization said there is still work needed in the areas of creating a Medicare payment board, quality improvement, and Medicare data release initiatives. Congress should also permanently repeal the current Medicare physician formula.
"The AMA will stay engaged in the process to ensure that the final bill that goes to President Obama for his signature will improve the healthcare system for patients and physicians," said Wilson.
Karen Ignagni, president and CEO of America's Health Insurance Plans (AHIP), said the current "debate is about whether the current legislation can work, bend the cost curve, and be sustained." She added that while the bill "makes important improvements in access and takes steps toward cost containment, it lacks accountability to ensure that costs will be brought under control."
Also, since the legislation also contains provisions that go into effect in the next year, that will create "significant disruption and instability for individuals, small businesses, and seniors."
Meanwhile, Nancy A. LeaMond, AARP's executive vice president for social impact, said the Senate bill "protects and strengthens Medicare's guaranteed benefits," while including reforms that "promote care coordination, reduce costly hospital readmissions, and eliminate waste and fraud."
Neither a record two-foot snowfall in Washington nor the gloom of night kept the Senate from voting 60-40 Monday after 1 a.m. on the first procedural vote to move ahead the Senate's healthcare reform bill.
The vote puts the Senate in position to have a final vote on the bill by Christmas Eve—and provides both sides time to debate the new 384-page manager's amendment released by Senate Majority Leader Harry Reid (D-NV) on Saturday morning.
Not surprisingly, gone is any public insurance option and an option to permit uninsured individuals ages 55-64 to buy into Medicare. Included is the provision proposed earlier this month in which multi-state private insurance plans would be offered under contract with the federal Office of Personnel Management, with at least one of the plans being a nonprofit entity.
But the issue that is likely to trigger major discussions this week is whether certain states are getting preferential treatment in the bill to ensure votes. On Sunday, Republicans were quick to point out that provisions were included in the bill for at least one state—Nebraska—and several others whereby the federal government would agree to pay for additional Medicaid costs incurred when newly insured enrolled. Nebraska is the home state of Sen. Ben Nelson, a Democrat who had considered not voting with his party in part because of the abortion language in the bill.
Senate Minority Leader Mitch McConnell (R-KY) said on Sunday that "when you decide to do something one-party only and you have 60 votes, you're open for business." He added: "It creates a smelly proposition. It exposes every one of those 60 to extract some special deal for them at the expense of everyone else in the country."
Sen. Kent Conrad (D-ND), speaking on Fox News Sunday, downplayed the controversy, saying that his "state gets a special deal" and "virtually every state gets some kind of differential treatment based on their situation." He added that North Dakota and "the other frontier states" under the bill will "get an increase in their Medicare levels of reimbursement because we're the lowest states in the country—and that doesn't offend me at all. It's, in fact, fair."
Among other provisions included in the manager's amendment are:
Medical loss ratios. Large group market plans must spend at least 85% of their premium revenues on clinical services and quality activities; for the individual and small group market, the ratio is 80%.
Excessive rate increases. A health insurer's participation in the state exchanges will depend on its performance.
Expansion of delivery system reforms. The secretary of Health and Human Services would have authority to expand successful Medicare programs, such as payment bundling and other value based purchasing projects, and could incorporate private sector payment models into the Medicare accountable care organization program.
Pre-existing condition exclusions for children. Health insurers will be immediately prohibited from excluding coverage for children with pre existing conditions.
Testing new tort models. States will be eligible for grants to test alternatives to civil tort litigation that emphasize patient safety, disclosure of healthcare errors, and early resolution of disputes.
Medicare tax. The Medicare payroll tax increase would be increased to 0.9%, from 0.5% that was proposed earlier, for individuals earning more than $200,000 or families making more than $250,000.
Cosmetic surgery tax. The so-called "Bo tax," is being dropped in favor of a 10% tax on indoor tanning salons.
The next vote on the Senate bill is scheduled for Tuesday morning. The bill is unlikely to garner any Republican votes.
Sen. Olympia Snowe (R-ME), who voted for the Senate Finance Committee bill, said Sunday on "Face the Nation" that "we're treating it as if it's the legislative appropriations at the end of the year. It's like the last train leaving the station; we're going to dump everything in there."
She said the current bill is "more expansive" than the Finance Committee bill--including for instance a new provision of long-term care insurance. "It...is a whole new entitlement that frankly will turn in the red five years after the benefits begin."
A new CDC report that about 1% of 8-year-olds have symptoms of autism spectrum disorder carries an important message for pediatricians, says Susan Hyman, MD, autism and developmental issues specialist for the American Academy of Pediatrics.
"What this report is telling us is that ASD is not a rare disease. And that developmental surveillance and screening is an incredibly important part of well-child care," says Hyman, division chief of Neurodevelopmental and behavioral pediatrics at Golisano Children's Hospital at the University of Rochester Medical Center.
While screening is already being done in most physician practices, Hyman says it has sometimes not been addressed.
"One of the reasons that physicians in the past have been reticent [to put a name on the disorder or diagnose the child] was the belief that there was nothing you could do.
"But though we may not be able to cure ASD, we can improve symptoms. Just last week, for example, there was an exciting paper published in the journal Pediatrics that looked at a model of early intervention that enhanced language and cognitive outcomes in very young children."
Physicians may also want to keep in mind the prevalence of autism in dealing with their office populations. "There are important research projects designed to, on a day-to-day basis, help doctors [with these patients]. For example, how do you keep children from running down the hall screaming when you say 'hello?'
"When you have people with developmental disabilities. Make them more comfortable in the office visit," Hyman says.
The CDC study relied on reviews of clinical and educational records rather than on parental interviews, which are believed to allow a more accurate capture of ASD incidence.
The ASD incidence report was published Friday in the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report Surveillance Summary. The authors defined ASD as autistic disorder or autism, Asperger's disorder, and pervasive developmental disorder not otherwise specified.
"These results indicate an increased prevalence of identified ASDs among U.S. children aged 8 years and underscore the need to regard ASDs as an urgent public health concern," the MMWR report said.
Nine of the 10 study sites—Florida, Alabama, Wisconsin, Pennsylvania, South Carolina, Maryland, Georgia, North Carolina, Missouri, and Arizona—reported an increase in ASD prevalence in 8-year-olds. Only Colorado was an exception.
"Identified ASD prevalence increased across all sex, racial, ethnic, and cognitive functioning subgroups," said Catherine Rice, lead author in a press briefing Friday. "For all sites, the most consistent pattern was the increase among boys," where it was four to five times higher than for girls, with one in 70 boys and 1 in 315 girls diagnosed with ASD.
The CDC study did not look at what might be causing the increased prevalence of ASD, and Rice did not rule out the possibility that better diagnosis, and improved record-keeping, may be identifying more children with these symptoms.
"Really, there's a multi-prong approach going on; we know there's no single cause for autism," but it may be a combination of environmental factors and genetics, some of which are inheritable and some which are not, says Rice.
Rice expressed similar views as Hyman about the report's take-home message for pediatricians.
"So at this point, what pediatricians should be doing is: one, listening to parents if they have a concern about their child's development, but also proactively following the screening guidelines; And if they have a concern, referring that child on for further evaluation, whether it's diagnostic or potential intervention."
After a long day of acid, partisan debate, Senate Democrats held ranks early Monday in a dead-of-night procedural vote that proved they had locked in the decisive margin needed to pass a far-reaching overhaul of the nation's healthcare system. The roll was called shortly after 1 a.m., with Washington still snowbound after a weekend blizzard, and the Senate voted on party lines to cut off a Republican filibuster of a package of changes to the health care bill by the majority leader, Harry Reid of Nevada. The vote was 60 to 40—a tally that is expected to be repeated four times as further procedural hurdles are cleared in the days ahead, and then once more in a dramatic, if predictable, finale tentatively scheduled for 7 p.m. on Christmas Eve.
A compromise on the healthcare overhaul that the Senate reached this weekend offered some relief for insurance companies, specifically for nonprofits that could win exemption from a new $6.7 billion tax. Part of the deal was an exemption for nonprofit insurance companies that met several requirements. One way to qualify is to spend an average of 92% of premiums on healthcare expenses. That spending measure, called a company's medical-loss ratio, is closely watched to determine how much insurers take in profits. Few companies, though, would qualify for that exemption. Goldman Sachs analyst Matt Borsch says just four insurers reached that threshold in 2008. America's Health Insurance Plans, the industry trade group, said federal data show that plans on average spend 87% of premiums on care.
The Senate nudged its health bill toward tighter restrictions on abortion coverage, a change that left advocates on both sides of the issue unsatisfied. Under a deal with Sen. Ben Nelson, women who receive a new tax credit to buy insurance would write a separate check with their own money for abortion coverage, and states would explicitly have the option of barring such coverage from plans sold on new insurance exchanges. However, the language is less sweeping than that adopted by the House in November, which abortion-rights groups interpreted as the most significant setback in Congress for their cause in many years. As it did in the House, abortion threatened to sink the healthcare bill at the last minute in the Senate. Nelson, an antiabortion Democrat, vowed to withhold his vote unless the bill included more stringent requirements to ensure no federal money goes toward paying for abortion. The debate centered around the insurance exchanges, where people who don't have coverage elsewhere will be able to comparison-shop for plans. The House language prohibits anyone who gets a tax credit from enrolling in a policy that covers abortion. The Senate would allow states in effect to match that restriction if they choose, but in other states the Senate language wouldn't be as restrictive. It says women can get the coverage if they write two checks to their insurer, one for abortion and one for everything else. The change in the Senate bill is expected to be adopted this week.
