Rates of potentially preventable hospitalizations for diabetes, chronic respiratory conditions, chronic cardiac conditions, and acute conditions generally were higher for adults aged 65 or older than for younger adults in 2007, according to a new Healthcare Cost and Utilization Project (H-CUP) review from the Agency for Healthcare Policy and Research.
However, between 2003 and 2007, rates of potentially preventable hospitalizations declined faster among older adults than among younger adults. The rates varied by medical condition:
Diabetes. Potentially preventable diabetes related hospitalizations occurred 2.6 times more often among older adults than among younger adults. Long term diabetes complications were the most frequent reason for diabetes stays among both groups, and occurred 3.7 times more often among older adults than younger adults. In contrast, short term diabetes complications occurred twice as often among younger adults than among older adults.
The rate of hospital stays for diabetes decreased by 8% among older adults between 2003 and 2007. However, the rate of these stays among younger adults rose 6%.
Chronic respiratory conditions. Potentially preventable stays for chronic respiratory conditions were 5.4 times more common among older adults as they were among younger adults. For older adults, there were 78.4 stays for chronic obstructive pulmonary disease (COPD) and 21.6 stays for asthma for every 10,000 older adults. In contrast, there were 8.4 stays for COPD and 10.1 stays for asthma for every 10,000 younger adults.
Chronic cardiac conditions. Hospital stays for chronic cardiac conditions that could have been prevented occurred over 10 times more often among older adults than among those ages 18 to 64. Congestive heart failure was the most common chronic cardiac condition leading to preventable hospital stays among both younger and older adults.
Potentially preventable stays for cardiac conditions among older adults occurred 14% less frequently in 2007 than they did in 2003. The rate of hospitalizations for these conditions declined by 8% among younger adults during the same period, as well.
Hypertension. The rates of potentially preventable hospital stays in 2007 related to hypertension were much lower for older adults (4.3 discharges per 10,000 younger adults and 16.6 discharges per 10,000 older adults) and angina without procedure (2.2 discharges per 10,000 younger adults and 7.6 discharges per 10,000 older adults).
Acute conditions. Among older adults, the rate of hospitalizations for acute conditions declined by 10% between 2003 and 2007. Bacterial pneumonia contributed in large part to this change—dropping from 179.2 discharges per 10,000 population to 149.8 discharges per 10,000 population. Bacterial pneumonia was the acute condition with the highest rate of hospitalizations among both younger and older adults (16.9 and 149.8 discharges per 10,000 population).
Will Tiger Woods come back to golf? Will his wife come back to him? Is Michael Jackson still alive and in seclusion? Will Elvis pick 2010 to reveal where he's been hiding for 33 years?
Yes, it's that time of the year again. The tabloids are making predictions for the year ahead, and it isn't only the trash journalists who are doing it. Mainstream media is making predictions about what lies ahead in sports, politics, and business for 2010.
As healthcare strategy journalists, we're not immune from inundation of press releases about what's likely to come in 2010. So I'm getting into the game too. Here's a look into what my crystal ball is telling me for next year about healthcare business strategy, and yes, I'll revisit these picks in one year to find out how well I did.
1. Meaningful healthcare cost reform will elude the scalpel.
It's too difficult politically to pass anything on health reform that will truly move the needle on cost control in healthcare. What has been touted as an overhaul that is transformational rather than incremental has died a death from a thousand cuts since its unveiling early last year. That's because our Congressional leaders have again proven how beholden they are to special interests, whether they represent drug companies, device makers, physicians or hospitals. Any time a proposal surfaced that would have drastically cut the flow on the money hose from which any of these groups are drinking, it was soon exposed as lacking the necessary political support to move through the Congress.
2. Coverage will increase, but to what level?
This will be the one area on which Congress will be able to say they've achieved their healthcare reform goals. One, it's politically popular to increase coverage for the uninsured among the democratic base. Two, it's the path of least resistance. Despite the fact that the United States is more than $1 trillion in debt, other countries still lend to us. That means truly tough choices on what to do on the government front will remain regulatory and incremental. Members of Congress don't have to apologize—at least until much later—for adding an unaffordable entitlement. All the interest groups win to some degree, while only future generations must foot the bill. Bravo, Congress. One day, however the piper will have to be paid. Just not now.
3. Employers will largely abdicate their push for value.
For a long time, employers have been pushing providers and health plans to justify their huge annual premium increases that have well outpaced inflation. They were right to push for transparency and quality improvement, and have had limited success in these areas. But with coverage extended to the uninsured, the pressure's off. They're already making workers bear much more of the costs of healthcare, and in the long run, that's a good thing, but the sense of urgency with which employers have been pressuring providers and health plans will have lifted. Perhaps where employers failed, consumers can make a difference? Perhaps. Consumer shopping for the best prices is the cornerstone of our economy, but it remains to be seen whether this force has met its match in healthcare.
4. The clinical staffing shortage will reassert itself.
For the past 18 months, physicians and nurses have been in the same economic boat as the rest of us. Retirement portfolios cut in half or worse, stagnant salaries. But over the past nine months, the stock market has come roaring back—not to pre-recession levels—but enough so that those who put off retirement may start thinking about it again. Add to that an influx of previously uninsured coming onto the rolls, and you have the makings of a staffing shortage that can't keep up with demand (see prediction 2). We've already seen this on a (relatively) small scale in Massachusetts. Nationwide, depending on the level of coverage the uninsured get in the final reform bill, the staffing shortage could quickly reach crisis levels.
5. Capital spending will remain recessed, just not depressed
This is one prediction for which I have to give at least partial credit to VHA Inc., which predicts that "hospitals will begin to experience a resurgence of spending for new and replacement capital equipment—a necessity as new technologies continue to force hospitals to upgrade."
While true, this prediction is more of a return to normalcy for healthcare. I don't share the optimism that capital spending will return to pre-recession levels anytime soon, however. Hospitals were burned by easy money once, as they invested in bricks and mortar as well as technology. Any bricks and mortar expansion will likely come outside the hospital, as more treatments move from inpatient to outpatient, but won't recover as quickly as spending for medical equipment, such as imaging, which many of my sources predict will become a larger piece of hospitals' income as reimbursement is ratcheted down for physician office-based imaging.
6. Hospitals will continue to acquire physician practices and increase hiring of physicians.
Anything that ties clinicians, especially physicians, closer to the hospital where they perform procedures on patients will continue to be hot (see prediction 4). That's why so-called “employment” of physicians—physicians don't like this term but that's what it is—will continue to be hot and will probably accelerate. Employment definitely ties them closer, and when structured correctly, allows physicians the level of autonomy they're looking for while moving toward accomplishing the goal of greater coordination of care and elimination of waste.
Take care, and let me know what you think of these predictions. I'd love to hear where you agree or disagree with my 2010 soothsaying. Corner office will be taking a break for the Christmas holiday next Friday (December 25), but will return the next week on New Year's Eve. Until then, Happy Holidays.
American Anesthesiology, Inc., has acquired Wilmington Anesthesiologists, a physician group practice in southeastern North Carolina with more than 39,000 cases annually. Details of the cash deal were not disclosed.
Wilmington Anesthesiologists has 24 physicians who practice at New Hanover (NC) Regional Medical Center, a 514-bed acute-care hospital that is a regional referral and trauma center, and at Cape Fear (NC) Hospital, a 133-bed community hospital that specializes in orthopedic services. The practice also provides services at nearby Atlantic Surgicenter and Wilmington Plastic Surgery Specialists.
"It was extremely important for us to partner with a solid force in anesthesiology that will provide support for the growth of our practice, and that will enable us to help shape the future of anesthesiology by establishing best practices through data acquisition in the clinical care setting," said Robert M. Shakar, Jr., MD, of Wilmington Anesthesiologists, who will serve as American Anesthesiology's medical director in Wilmington.
Wilmington Anesthesiologists has been the exclusive provider of anesthesia services at New Hanover Regional Medical Center for the past 25 years, and serves the surrounding communities in southeastern North Carolina and northeastern South Carolina.
American Anesthesiology, a national anesthesiologists' group practice, is based in Fort Lauderdale, FL, and is a subsidiary of MEDNAX, Inc., which now has more than 550 anesthesiologists and advanced practitioners providing patient care in Virginia, Georgia, and North Carolina.
MEDNAX, Inc. also provides neonatal, maternal-fetal, and pediatric physician subspecialty services as well as anesthesia services. Subsidiaries include Pediatrix Medical Group, the neonatal ICU specialists.
While the Senate focused attention Thursday on the defense spending bill until the wee hours of the morning, Senate Republicans began to put pressure on another area to stop the healthcare reform bill. A current GOP governor and four GOP senators, who were once governors (from New Hampshire, Idaho, Nebraska, and Tennessee), said they oppose the "unfunded mandate" of Medicaid expansion included in the bill.
In Washington, Mississippi Gov. Haley Barbour said the current proposal in the Senate bill to permit individuals making less than 133% of the federal poverty level [it's 150% in the House bill] to receive Medicaid could lead to big tax increases—especially in those states required to balance their budgets every year. Under the bill provisions, the federal government would pay the states three years to fund the new Medicaid population; the states would then pick up the tab after that.
Barbour described this idea as like "leaving mackerel out in the moonlight ... the longer it's out there, the worse it stinks." For his state alone, he said, Medicaid, which is one of the most costly programs in the state, would cost Mississippi taxpayers $1.3 billion over the next 10 years.
Sen. Judd Gregg, who was once the governor of New Hampshire, warned of the "death spiral" that could occur if states had to find funding for the estimated 15 million people added to the Medicaid rolls, as proposed by the bill.
He said the increase in Medicaid beneficiaries would have a "disproportionate effect" on private insurance. Since Medicaid pays providers about 60% of the cost of care for beneficiaries, providers would be forced to charge more to private insurers to make up the difference, he said.
One group, though, that is supporting the Senate Democrats' efforts to expand coverage is Families USA, which released on Thursday a report, called "At a Crossroads," that looks at what type of healthcare coverage is ahead for everyone. In an accompanying letter, Families USA Executive Director Ron Pollack said the group supports the bill, even if it lacks a "robust public plan option."
Families USA, a national health care advocacy group, used Census data and Congressional Budget Office's national data to estimate coverage gained under the bill and the number of uninsured by 2019. It reported that:
The following 10 states are projected to have the largest gains in coverage by 2019: Arizona, New Jersey, Ohio, North Carolina, Illinois, Georgia, New York, Florida, Texas, and California.
In 2019, the coverage gains in these 10 states will range from 821,000 to 4.527 million people.
If health reform fails, those same 10 states would have the largest losses in coverage by 2019.
Some might say that there's no juice left to squeeze from the cost of providing care, but a new report from PricewaterhouseCoopers' Health Research Institute says health leaders are going to have to try.
"The primary emphasis for all healthcare organizations in the year ahead will be on reducing costs and creating greater value in the health system, a focus that will have a domino effect from one sector to another, and (will) redefine roles, responsibilities, and relationships," says David Chin, MD, a partner and leader of the institute.
The report, entitled appropriately enough "Squeezing the Juice Out of Healthcare," lists 10 issues of concern for health providers, including insurers, hospitals, physicians, pharmaceutical and life-sciences companies, and even community groups and municipalities.
They are:
1. Reducing Costs. Hospitals, physicians, and other providers will have to squeeze every penny out of their operations, including renegotiating contracts with suppliers on everything from food to medical devices and pharmaceuticals. "All reform will be in the context of future spending, particularly in light of Medicare and Medicaid absorbing an increasingly large part of the GDP," according to the report.
This will mean increasing reimbursement pressure, with physician practice models beginning to adapt. Payers will grapple with Medicare Advantage reimbursement leveling, and perhaps fees or taxes on insurers. Pharma will be more intensely restricted in its marketing activities and data usage, rebate changes and at the same time, maintaining its $80 billion contribution agreement with the Obama administration.
2. Regulatory Change. Dozens of new agencies and grant programs, reimbursement, and pricing pressures, with increased governmental oversight, will impose new requirements on healthcare providers.
The proposed Physician Payments Sunshine Act would require pharma and device companies to disclose consulting fees paid to physicians, health insurers, pharmacists, and others. Non-labor costs can make up half of most hospital expenses, and executives say they're scrutinizing purchases in areas of biomedical engineering, energy, security, and even parking as places to cut. Even food and nutrition services are on the chopping block, as are laundry and linen services.
3. Incentives and Value-based Purchasing. Fewer than half of providers have implemented all but the most basic electronic health record functions.
"2010 will be a double-bonus year for physicians who act quickly to take advantage of government incentives to adopt electronic medical records and e-prescribing. Those who do not will face potential penalties later. This new carrot and stick model indicates the government's changing role from a 'passive payer' to an 'active buyer,' according to the report.
4. Focus on fraud. With an estimated $1.6 billion in savings said to healthcare fraud detection, prevention, and recovery, healthcare organizations will need to tighten their internal controls. Pharmaceutical executives now face jail time for off-label marketing violations and hospitals are looking nervously at the Centers for Medicare and Medicaid Services Recovery Audit Contractor program.
5. Technology. Stimulus funds from 2009 are boosting broadband funding, with an eye to converge technology and telecommunications companies. For example, Verizon's Telehealth Collaboration Services Initiative provides remote consultation and technology for continuing medical education and virtual encounters for hospitals, physician practices, labs, and government agencies. GE Healthcare and Sprint are partnering with San Antonio's Methodist Healthcare to create a wireless infrastructure for anytime communication.
6. Prevention. Pharmaceutical and life sciences companies will be more involved in promoting prevention and seeing results in patient outcomes. "In 2010, expect to see greater alignment of incentives between pharmaceutical companies, payers, and providers," as well as retailers to address education, clinical effectiveness, product safety, wellness, and compliance, according to the report.
7. Physician involvement. Doctors will seek greater stability and electronic connectivity. Accountable care organizations will require all providers to reevaluate their relationships, operational infrastructure, payer contracting, and overall funding models.
8. Alternate care models. Expect an increase in the number and scope of services offered outside physicians' offices and hospitals, perhaps even in workplaces and retail health clinics. Home health services, enabled by technology, will be given a boost through e-mail, telehealth, and remote patient monitoring.
9. Disaster planning. Another wave of H1N1 will put more pressure on public health outbreak response, vaccine supply and distribution, better communication, consideration of bed capacity, sick leave policies, and the role of funding mechanisms and contingency plans.
10. Social responsibility. Community-oriented health services and consumer access will involve neighborhoods and municipalities in an effort to promote personal responsibility. Many of these efforts will continue to be boosted by grants, such as the Indiana Tobacco Prevention and Cessation group and the AARP Blue Zones Vitality Project in Albert Lea, MN, which seeks to prolong life expectancy by at least two years.
Congress shouldn't look at Texas tort reform as a model to control national healthcare costs because "Texas has one of the worst healthcare systems in the United States," warns Public Citizen, a national consumer group.
In its report, "Liability Limits in Texas Fail to Curb Medical Costs," the patient advocacy group said Texas reforms, which place a $250,000 per defendant cap on pain and suffering awards similar to that in California, have not held down costs, as some in Congress have touted.
"Members of Congress have conjured the supposed benefits of the Texas law out of thin air," said David Arkush, director of Public Citizen's Congress Watch division. "The only winners have been the insurance companies, and, to a lesser extent, doctors."
Since the liability cap took effect in 2003, "Texas has either failed to improve or grown even worse compared to other states on almost every measure" in healthcare, including its cost of care, rate of uninsured, and access to care. "Texas has regressed," the group reported.
The findings draw statistics from the Dartmouth Atlas of Healthcare, the U.S. Census Bureau health insurance data, and surveys from the Agency for Healthcare Research and Quality.
"This report is completely erroneous," says William Fleming, MD, president of the TMA. "The goal of tort reform was never cost containment. It was to improve access. This report is an apples and oranges comparison."
Before tort reform in Texas, the state was plagued by a physician shortage, especially in rural areas, he says. Throughout the state, high-risk specialists, such as neurosurgeons and obstetricians, were hard to find.
"There were no neurosurgeons in the Rio Grande Valley, and people who needed brain surgery had to come to Houston. Often they died en route," Fleming says.
"There were many counties in the state that had no obstetricians, and women had to travel hundreds of miles for prenatal care," says Amanda Engler, spokeswoman for the THA. Many obstetricians had stopped delivering babies because of exorbitant malpractice costs. Now, these areas are better able to successfully recruit, she says.
Pam Udall, spokeswoman for the TMA, adds that the number of primary care doctors grew 7.76%, which was faster than population growth in Texas during the three years after reforms took effect.
And in the last three years, the number of primary care doctors "has outpaced population growth by 33%, an incredible accomplishment being that Texas is the seventh fastest growing state in the nation and far and away the most populous of the fast-growth states," she adds.
Fleming says that before tort reform in Texas, there were only two medical malpractice companies willing to insure doctors. Now there are 10.
Dan Stultz, MD, president/CEO of the Texas Hospital Association, also responded to the Public Citizen accusations.
"The medical liability reforms passed in 2003 have produced the desired result: more doctors are willing to practice medicine in Texas. As we work to expand healthcare coverage and improve the delivery system, preserving Texans' access to medical services is critical," says Stultz.
According to the Public Citizen report, the cost of healthcare has nearly doubled the national average, spending increases for diagnostic tests exceed the national average, and the number of uninsured increased and remains the highest in the country, all since liability laws took effect.
"Access to care in Texas remains a crisis," according to Public Citizen. "Reductions in malpractice cases [are] a windfall to doctors and insurance companies."
Additionally, the group said, the cost of health insurance has more than doubled, the growth in the number of doctors per capita has slowed, and the number of doctors per capita in underserved rural areas has declined.
Though Fleming says that physician medical malpractice premiums have dropped 37% since 2003, the Public Citizen report said that's "the only improvement."
The advocacy group issued its report because of claims made by several member of Congress, specifically Sen. Jon Kyl (R-AZ), who proposed a Senate health insurance amendment that was filed Dec. 9.
"Liability opponents credit the Texas law with luring droves of new physicians to the state. For example, Kyl claims, 'Because of the Texas reforms, Texas saw an overall growth rate of 31% in the number of new physicians,' according to Public Citizen.
"In fact, the overall population of physicians in Texas has grown at a far slower rate than Kyl claims. But even the increase Texas has seen can mostly be explained by growth in the state's population. The state's per capita physician population increased by only .4 % from 2003 to 2009—which is far less than the 8% per capita increase during the equivalent period of time leading up to the law, from 1997 to 2003."
"The shortage of doctors in rural Texas—for which litigation is often blamed—grew slightly worse after the liability restricts were enacted," the report continued. "From 2003 to 2009, the per capita population of doctors in non-metropolitan areas declined by .8%.
When Senate Democratic leaders agreed this week to remove a public insurance plan from their massive healthcare bill, they did more than quash a liberal dream of expanding the government safety net. They effectively pinned their hopes of guaranteeing coverage to all Americans on a far more conventional prescription: government regulation. The change sprang from a compromise made to placate conservative Democrats wary of a new government program. But shorn of a "public option," the Senate healthcare bill has reverted to a long-established practice of leveraging government power to police the private sector, rather than compete with it. Despite the resistance among Republicans and conservatives to more government regulation, even the insurance industry has agreed to broad new oversight of their business in exchange for the prospect of gaining millions of new customers. The expanded regulation of insurance programs ultimately could ripple through the entire healthcare system, affecting how doctors, hospitals, and other providers care for their patients.
A widening gulf in the health status of blacks and whites in Chicago comes even as disparities between the two races nationally have remained relatively constant, a new study has found. The disparity is particularly jarring in five areas: death from all causes, heart disease mortality, breast cancer mortality, rates of tuberculosis, and the percentage of women who received no prenatal care during the first trimester of pregnancy. Nationally, the racial gap got worse from 1990 to 2005 for six of the 15 health indicators researchers studied. However, in Chicago, disparities worsened for 11 of the 15 indicators, according to research by the Sinai Urban Health Institute, published online Thursday in the American Journal of Public Health.
In the great healthcare debate of 2009, President Obama has cast himself as a cold-eyed pragmatist, willing to compromise in exchange for votes. Now ideology—an uprising on the Democratic left—is smacking the pragmatic president in the face. Stung by the intense White House effort to court the votes of moderate holdouts like Senator Joseph I. Lieberman, independent of Connecticut, and Senator Ben Nelson, Democrat of Nebraska, liberals are signaling that they have compromised enough. Grassroots groups are balking, liberal commentators are becoming more critical of the president, some unions are threatening to withhold support, and Howard Dean, the former Democratic Party chief, is urging the Senate to kill its health bill. The White House scrambled Thursday to tamp down the revolt, which has been simmering for weeks, but boiled over when the Senate Democratic leadership, bowing to Lieberman, scrapped language allowing people as young as 55 to buy into Medicare.
The White House and Senate Democratic leaders seem willing to give Senator Ben Nelson, Democrat of Nebraska, just about anything he wants to win his support of major healthcare legislation. Anything, that is, but the item at the top of Nelson's wish-list: air-tight restrictions on insurance coverage for abortions. The bid to win Nelson's support has become a race against the clock. The Senate majority leader, Harry Reid of Nevada, has developed plans for a series of votes beginning at 1 a.m. Monday and round-the-clock Senate sessions intended to meet his deadline of completing the healthcare bill before Christmas. But Reid is still at least one vote short of the 60 he needs to move the bill ahead, and as much as anyone, Nelson appears to hold the legislation's fate in his hands.
