In his opening remarks Tuesday at the Institute for Healthcare Improvement's (IHI) 21st annual national forum on quality improvement, IHI President and CEO Don Berwick observed how many healthcare organizations have made great strides in addressing issues, such as patient-centered care, patient safety, and chronic disease care innovations. But this is occurring during a time of great unease at the national and even international levels—where solid answers to healthcare costs and coverage are becoming more difficult to come by.
Berwick told the 5,300 attendees in Orlando Tuesday that with current reform efforts in Washington—with an estimated 10-year, $1 trillion price tag—have also come with a debate that's balancing two options: Spend more money or do less for people. But neither of those ideas is going for work very well for the current generation or future generations, he said.
Increased spending on healthcare is "theft—theft of healthcare from schools and roads and museums, and the social safety net. That's theft from the future," Berwick said. Since spending more on care and doing less for people isn't an option, that creates a "mega-pickle."
And he doesn't see Congress making the major changes to alter this.
"Congress hasn't led us to a new care system, and I don't think it will. Congress won't give America even a vague prescription—much less a detailed set of rules for that," he said. "How could Congress possibly know enough to specify for every community, the exact design for … care that is safe, effective, patient-centered, timely, efficient, and equitable?"
To understand why they may be stuck in this situation, healthcare providers and organizations may want to review the "Tragedy of the Commons," a term from an article that appeared in Science magazine in 1968. It referred to a pasture or commons that has an optimum number of sheep—where there are just enough not to destroy the area. But as sheep are added, the area is soon overpopulated with sheep and is destroyed.
This can be related to healthcare reform—with all the stakeholders including hospitals, physicians, nurses, insurers, pharmaceutical manufacturers, suppliers, and even patient groups. "Like the villagers [in the commons analogy], rational healthcare stakeholders are eroding the common good simply by doing what makes sense to each of them separately," Berwick said. "In the short term, we each win. But in the long term, we all lose."
"This is a world with limits [and] it can be used up," Berwick said. But healthcare is not entitled to everything it has "and surely not entitled to everything it can get."
"Healthcare does not need everything it can get—not by a long shot. Not if what it's trying to do is give us what we need—comfort, answers, vigor, years, and health. We can have what we want," he said.
He added some systems are making progress in recognizing and dealing with limited resources in providing care in their communities, such as Cedar Rapids, IA; Everett, WA; Tallahassee, FL, and La Crosse, WI.
At the meeting, Kavita Patel, who assists the president's senior advisor, Valerie Jarrett, at the White House, said current reform legislation does not specifically define quality or even how to measure it; this is likely to fall under the review of the healthcare organizations.
While Washington can write the rules, the odds of "re-form" will remain zero unless action is closer to home—or essentially closer to the providers of care. Berwick suggested some ideas to get started:
Understand your "healthcare commons"—its limits and boundaries, who uses its resources, and who is served.
Adopt a goal—such as over the next three years, reduce total resource consumption of your healthcare system by 10%. This would be achieved without rationing or exclusion of needed services.
Develop it fast—"because there isn't much time left," he said. "Do not wait for external rules to be made or to change. Do it yourself."
"We can wait for the rules to be written by others and for the laws on tablets chiseled by others to rescue us—but those rules will be less wise than the ones we can write," he said. "It is a very tough choice: Get everything we can or respect everything we have been given."
HIPAA privacy and security officers would probably be thrilled to receive a letter from the Office for Civil Rights (OCR) with "HITECH guidance" written on the envelope.
But that hasn't happened, and it's anyone's guess when it will.
Experts told HealthLeaders Media they expect OCR, the HHS agency that enforces the HIPAA privacy and security rules, to deliver guidance on business associate (BA) contracts, meaningful use, clarifications on security breach notification, and perhaps security rule compliance for BAs. When that information is delivered, however, is unknown.
The date for compliance with the HITECH, the privacy and security law signed into law earlier this year, is known—February 17, 2010.
And you can certainly work now on your BA contracts and prepare for HITECH compliance.
Here are six tips to help:
Remember: Compliance is not going away. Some important regulations, such as the breach notification interim final rule, have been set. Regardless of what OCR does for guidance, the compliance date with major HITECH regulations is February 17, 2010. "You're still going to have that compliance date," says John R. Christiansen, founder of Christiansen IT Law in Seattle. Christiansen will be one of the speakers on the HCPro, Inc., January 14 audio conference, "Business Associate Action Plan: Comply with HITECH by February Deadline."
Start to comply now. Don't wait for OCR guidance to make a move. "I don't know quite what the guidance is going to say," Christiansen says, "but at some point you've got to get off the fence and say you're going forward and taking action."
Create a form for new contracts. Have a form in place for new contracts between BAs and covered entities. "Develop a form and adapt it going forward," Christiansen says. The lawyer says that as far as existing BA contracts go, it will be "really difficult to track down all of your BA contracts and assemble them." Some of the BAs may not know why you're contacting them. "It can be a daunting process," Christiansen says.
Research how HITECH wording applies to contracts. HITECH says covered entities must incorporate the new provisions into their BA contracts. Does that mean they're automatically a part of the BA contract? Or does each covered entity have to update the contracts to reflect the HITECH changes? Christiansen says he's heard lawyers leaning toward each scenario. He says he advises clients to amend their own agreements. That way, they can include their own language that works better for their relationship with the BA. "Instead, you've got this law automatically applied," Christiansen says. "That may be fairly hard to work with."
Coordinate security breach notification in your contract. "It's much better to negotiate that before you've got a problem rather than in the heat of the moment," Christiansen says. "It's very important to cover that in advance to the greatest extent you can."
Spell out the BA's security obligations. Specify safeguards, and require coordination on how they do things. "If you're accessing the same information using the same service together, that can get a bit complicated," Christiansen says. "If you've got different security standards for each, that can get unnecessarily complicated. It's an opportunity to have a dialogue you ought to be having."
Thanks largely to federal stimulus money, most states protected and even expanded coverage under Medicaid and CHIP for children and parents in 2009, despite a deep recession, according to a new 50-state survey from the Kaiser Family Foundation's Commission on Medicaid and the Uninsured.
However, that coverage could be threatened if the economy continues to sputter, when the temporary federal assistance under the $787 billion American Recovery and Reinvestment Act expires at the end of 2010, and before any health reform coverage would begin, the survey found.
The annual survey of eligibility rules, enrollment and renewal procedures, and cost-sharing practices in Medicaid and CHIP for children and parents found that most states in 2009 continued to expand and simplify their Medicaid and CHIP programs even as they faced the bleakest economic picture in years and severe budget pressures. However, budget shortfalls did result in cutbacks in some states.
"The renewal of CHIP and the fiscal relief and eligibility and enrollment protections for Medicaid in the ARRA proved critical to enable states to continue their commitment to providing coverage to millions of low-income families," said Diane Rowland, executive vice president of the foundation and executive director of the KCMU, in a media release. "However, even with signs of economic recovery, state revenues are still mired in a severe slump and, faced with the end of enhanced federal money after 2010, fiscal shortfalls are likely to cause states to consider significant cuts to Medicaid and CHIP."
The survey found overall progress nationally in expanding public coverage or making it easier to access. However, wide variations in coverage persist. Among the survey findings:
Forty-seven states cover children in families with an annual income at or higher than 200% of the federal poverty level ($36,620 for a family of three), with almost half (24 states) covering children in families with incomes at or greater than 250% of FPL ($45,775 for a family of three).
Parent eligibility levels continue to lag, and the disparity between children and parents is growing. Currently, the median income eligibility limit for children is 235% of FPL ($43,029 for a family of three) compared to the median for a working parent at 64% of FPL ($11,718 for a family of three).
Twenty-six states bolstered coverage for low-income children, parents, and pregnant women, either by expanding eligibility, simplifying enrollment procedures or reducing financial barriers. Children were the chief beneficiaries of expansions in 2009, with 19 of those 26 states improving access to coverage for children by increasing eligibility, simplifying procedures, and eliminating premiums.
Fifteen states scaled back coverage in their CHIP programs in 2009. Although no state reduced eligibility for children, California and Tennessee froze CHIP enrollment for some time in 2009. Other actions included increases in waiting periods, retractions in eligibility simplifications, and relatively modest increases in CHIP premiums. Even after recent increases, the median CHIP premium payment for two children in a family with income at 200% of FPL remains modest at $480 annually, representing 1.3% of family income. Arizona also eliminated parent coverage and Montana retracted its simplified income verification procedures in CHIP.
The survey found that states’ commitment to providing Medicaid and CHIP coverage to low-income children and families will continue to be tested in 2010 as dismal state budget circumstances persist. Recent forecasts indicate states will face even bigger shortfalls in the upcoming fiscal year.
ARRA assistance will expire at the end of December 2010, and with it the federal requirement that states maintain eligibility levels and impose no enrollment barriers. KFF said that that raises the prospect of substantial state cuts in Medicaid and CHIP that could reverse recent expansions and undermine the base of coverage for low-income families upon which broader health reform efforts seek to build.
Democratic Senate negotiators struck a tentative agreement to drop the government-run insurance plan from their overhaul of the healthcare system, hoping to remove a last major roadblock preventing the bill from moving to a final vote in the chamber, the Washington Post reports. Under the deal, the government plan would be replaced with a program that would create several national insurance policies administered by private companies but negotiated by the Office of Personnel Management. If private firms were unable to deliver acceptable national policies, a government plan would be created.
Senate Majority Leader Harry Reid said that he and a group of 10 Democratic senators had reached "a broad agreement" to resolve a dispute over a proposed government-run health insurance plan. Reid refused to provide details, but other senators said the tentative agreement would sideline but not kill the "public option" championed by President Obama and liberal Democrats in Congress, the New York Times reports. Reid's comments came a few hours after the Senate rejected a proposal to ban coverage of abortion by health plans that would insure millions of Americans under the Democrats' bill.
Signature Healthcare, which includes Brockton Hospital and the 150-physician Signature Medical Group, has become the second Eastern Massachusetts healthcare provider in the past three weeks to form a clinical affiliation with Tufts Medical Center in Boston and its Floating Hospital for Children. The new clinical affiliation will expand existing ties in pediatrics, cardiovascular disease, orthopedics, surgical services, obstetrics, and gynecology, and build new partnerships in bariatrics, neurology, and cancer care, the Boston Globe reports.
Pennsylvania-based Aria Health executives said that staff members did not violate protocols in dealing with Joaquin Rivera, the 63-year-old man who died while waiting for care in the health system's Frankford hospital, but added that protocols would be changed in the hope of avoiding another waiting-room death. Aria officials think Rivera died 11 minutes after walking into the hospital. The hospital was not alerted to his death until another person in the waiting room reported that someone had taken Rivera's watch.
Aetna Inc. spent less money on patient care for some small businesses than it originally reported in regulatory filings, according to a Senate committee scrutinizing insurers' profits as Congress pushes to overhaul the healthcare system. The Senate Committee on Commerce, Science and Transportation launched an investigation last summer into the percentage of premiums insurers spend on medical care versus profits and other administrative expenses. In a statement, the committee said Aetna overstated by $4.9 billion the amount of money it spent on patient care for small businesses. As a result, the insurer's medical-loss ratio for small businesses was 79%, not the 82% Aetna initially reported, it said.
The United States ranks near the bottom in life expectancy among wealthy nations despite spending more than double per person on healthcare than the industrialized world's average, the Organization for Economic Cooperation and Development announced. Life expectancy at birth in the U.S. was 78.1 years in 2007, according to the Organization for Economic Cooperation and Development. That's a year less than the OECD average of 79.1, and puts the U.S. just ahead of the Czech Republic, Poland and Mexico, where spending on healthcare is many times less per person, the Paris-based organization said. Total U.S. spending on healthcare was $7,290 a person in 2007, nearly two-and-a-half times the OECD average of $2,984. The figures include spending by both individuals and governments.
President Barack Obama announced he will allocate nearly $600 million from the $787 billion economic stimulus plan to help create jobs at 85 community health centers. The White House said nearly $600 million would be awarded to help pay for major construction and renovation projects at 85 community health centers across the country and assist networks at the centers to move to electronic records.
