Thomas E. Jackiewicz has been named CEO of UC San Diego Medical Center, which includes Hillcrest Medical Center, Thornton Hospital, Moores UCSD Cancer Center, Shiley Eye Center, and the Sulpizio Family Cardiovascular Center that is scheduled for completion in 2011. Jackiewicz previously served as associate vice chancellor and CFO for Health Sciences at the UCSD. During his career, he served as COO of Columbia University Medical Center, senior associate chair for finance and administration at the Stanford University School of Medicine, director of finance and administration for Oregon Health Sciences University, and director of business and financial operations at the University of Pennsylvania Health System.
When health insurance companies adopt for their own employees the cost-effective healthcare delivery strategies of other large businesses, this is a good indication that the trend is more than a passing fad.
Highmark Inc., for example, is following the lead of companies like Toyota, Disney, and Harrah's and this month opened on-site healthcare clinics and pharmacies for its 10,000 or so employees at its two main operations centers in Pittsburgh and Camp Hill, PA.
Rich Little, vice president of compensation and benefits at Highmark, says opening the clinics is a logical progression along the wellness-at-work spectrum.
"We want to focus on the preventive healthcare because that is where we've been. If you go back five years in this story, our CEO (Kenneth Melani, MD) has really been pushing us in the direction of preventive care, consumerism, taking better care of your health, and being more engaged," Little says.
Take Care Health Systems, within Walgreens Health and Wellness Division, has been contracted to operate the on-site clinics, each of which will be staffed during the business day by a full-time physician and a nurse practitioner, as well as office managers and receptionists.
Highmark spent about $1.5 million to get the two clinics operational, but expects to recoup $200,000 in savings within the first year, and as much as $5 million over the next five years. Much of that savings will come through increased productivity and the reduced time away from work for employees trying to access a physician or seeking care away from the work site. Little says employees are excited about the easier access to care, at a reduced price.
"We did the return-on-investment study with Take Care and one of the things they cited was a Rand study in September that showed the costs of providing services at a facility like this are about 30% to 40% cheaper than a primary care office or an urgent care clinic, and 80% cheaper than the emergency room," Little says. "The other thing is the plain concept behind preventive care itself. If you can get your high blood pressure diagnosed or cholesterol under control, you are less likely to experience a catastrophic event in the future."
The clinic isn't available to family members, but the pharmacy is. The cost of the clinic depends upon the employee's insurance plan, with higher out-of-pocket expenses for high-deductable plans.
Little says the health insurance industry has an obligation to try out progressive and potentially cost-saving healthcare delivery strategies within the workplace. "This is a step in that process of going out and trying to get people engaged in taking care of themselves," he says. "The healthcare reform discussion also has quite a bit of discussion about preventive care and making sure people get to the physician and we feel that is our responsibility. We test a lot of these things internally at first. We want to make sure there is validity to it before we try to push it out into the market and to our customers."
Little says that other wellness and preventive programs at Highmark have shown to be very cost effective, resulting in $1.65 in savings for every $1 spent on things like the lifestyle rewards step program. "I expect we will be able to demonstrate a similar type of ROI here. That makes it very appealing to a customer," Little says.
The only negative that I can see in these on-site clinics is that they are limited only to very large companies that can absorb the up-front costs, and have the economies of scale to make them work. Little concedes that it would be difficult for a company with 50 or 100 employees to follow the model. "I'm not sure whether we are going to be able to do that in the short term," he says.
The answer for smaller companies might be to pitch in and split the cost of establishing a clinic, for example, centrally located in the industrial park where they're located.
I'm a big advocate of retail medicine and on-site clinics. The nation's healthcare delivery system has done a poor job making itself more accessible for our 24/7 culture. Not even banks have the same restrictive hours of operation as that of most physicians' offices. On-site health clinics represent a common sense and cost-efficient way to deliver medical care. This is not a passing fad.
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Federal health officials last week issued caution about "a worrisome spike" in serious pneumococcal disease, as seen in surveillance centers such as in Denver, where in October levels nearly tripled those normally seen for that month.
"The findings in Denver probably reflect findings that are occurring in other parts of the country where the surveillance hasn't been as intensive," said Anne Schuchat, MD, director of the Centers for Disease Control and Prevention's National Center for Immunization and Respiratory Diseases.
Pneumococcus is a type of bacteria that takes hold in the lung after influenza viral infections reduce the lining of the respiratory tract. The infections can invade the bloodstream, where they can be especially difficult to kill.
"We were sort of looking for this last spring, and didn't see a problem," Schuchat said at a media briefing Wednesday.
Schuchat said that in Denver, most of the severe pneumococcal illnesses have been in younger people, under age 60.
She urged that people protect themselves with the pneumococcal vaccine. "We strongly recommend that adults with chronic conditions like diabetes, emphysema, chronic heart, lung, liver disease take advantage of the pneumococcal vaccine," she said. Only 25% of adults at high risk under the age of 65 have been vaccinated.
Officials said the CDC would have another update on the uptick in severe pneumococcal disease Monday.
November marks the 10-year anniversary of the Institute of Medicine's "To Err Is Human," the first of its 11-volume "Quality Chasm" series on improving patient care and avoiding mistakes.
Since the landmark report, health providers have been chagrined by the revelation that they were killing "a jumbo jet" full of passengers every day, about 98,000 preventable deaths a year. And many of them reacted to the allegation by launching a broad spectrum of efforts to reduce medical mistakes.
But are we really better today at preventing mistakes and safeguarding our systems from causing harm than we were 10 years ago?
"We're safer in many more places, and more of the time," says James Conway, senior vice president of the Institute for Healthcare Improvement in Cambridge, MA.
"We're seeing very courageous people in many organizations doing exceptional work. We're seeing sobering discussions about the circumstances in which patients died unnecessarily, confronting the reality of the patient who was harmed with graphic detail, using the name of the patient, and their age."
There is in many places, Conway says, more accountability and more responsibility. There is more acknowledgment that mistakes are preventable, and not just part of the background noise that says it's OK because bad things happen in medicine sometimes.
But on a national level, he's not so sure. He's concerned that in many regions, facilities have not become "expert at looking for trouble. We're just learning to identify what harm is," he says.
First the good news.
Many states now require reporting of adverse events and some require public reporting of hospital-acquired infections, patient falls or pressure ulcers. In some states, health officials hold press conferences to publicize hospital errors that caused, or had the potential to cause serious patient harm or death. At least one state, California, imposes hospital fines and publishes the incident report in all its excruciating detail on the Web.
Medical residents' hours are now restricted to prevent errors caused by fatigue.
Providers in many hospitals that normally compete have joined hands to unify how they label high-risk intravenous medications, to avoid a new doctor or nurse from misusing a potentially lethal drug because the facility's coding or storage system was not the same as their previous hospital.
The Institute for Healthcare Improvement launched a number of safety strategies, including its "100,000 Lives Campaign." Following that campaign, the IHI launched its "5 Million Lives Campaign" to understand and address those medical mistakes, an estimated 40,000 per day, that injure patients and take a toll on their quality of life.
Providers are setting goals for their communities. Hospitals are starting to use the IHI "global trigger tool" to more accurately measure areas of care that might be causing avoidable harm, including the 28 adverse events now required to be reported.
Facilities were urged to adopt a "no-blame" system to encourage providers to report their own missteps, in the chance the practice or situation might be easily repeated by a colleague. Disclosure of those mistakes and transparency has become acceptable at many facilities as well.
Central Line Associated Bloodstream Infections have been reduced.
Many facilities are using "checklists" before beginning surgery or a complex procedure.
The Centers for Medicare and Medicaid Services will no longer reimburse health facilities for the cost of caring for a patient with a preventable hospital-acquired infection.
More attention is being paid to physicians' diagnostic errors, and the importance of being candid with patients and patients' families when preventable errors occur.
But many significant challenges remain.
Hospital mistakes
On the negative side, lots of serious mistakes are still happening. Earlier this month for example, Rhode Island Hospital, the state's largest, was fined $150,000 for performing its fifth wrong-site surgery since 2007. The latest incident prompted the state to order the facility to install video cameras in all its operating rooms.
Foreign bodies, such as sponges, clamps, hemostats, and towels, are too often left inside patients during surgery, because surgical teams don't take seriously enough requirements that they count and record all such items incoming and outgoing.
Infection control lapses
Kathy Warye, chief executive officer of the Association for Professionals in Infection Control and Epidemiology, said a major issue is lack of scientific information about bacterial, viral, and fungal infections that are so frequently transmitted in healthcare settings.
"We don't understand some of these infections, like C. difficile, well enough to know whether they can be prevented," she says. "Science hasn't yet filled the gaps."
Aside from that, she says, another stumbling block is the lack of healthcare executives' support to control preventable infections.
Health executives, she says, "still aren't fully cognizant of what infections ultimately cost," Wayre says. "They look at infection control as a cost center, and in the last economic downturn, 20% of respondents [to a survey] said they had to cut back on surveillance, and 41% said their resources were cut across the board.
Today, 29 states require some public reporting of healthcare infections. And if the current House version of health reform bill passes, it will be 100%.
"Transparency leads to improved outcome, and in many states there is evidence that it's played a key role," Wayre says.
Hospitals need to conduct comprehensive risk assessments to determine if they should be screening patients on admission for infections they may have acquired in their communities, but which could pose serious health issues for other patients, adds Wayre.
Medication errors
It was just two years ago that actor Dennis Quaid's twins were given Heparin in an adult dose that was 1,000 times stronger—rather than the proper dosage of Hep-lock.
Allen Vaida, a pharmacist and executive vice president of the Institute for Safe Medication Practices, says "we have made great strides in understanding that medication errors are an issue, but we still have a long way to go."
Vaida says hospitals should implement barcoding of medications. "Only 5-20% of hospitals now do it. We should be striving for 100%," he says.
Second, he says, "we have to do a better job learning from others." Too many hospitals see tragic mistakes that happen elsewhere and say, "That happened in California. I'm in Ohio. It doesn't happen here.
"We need to realize we're in a risky business, and ask the question 'Could that happen here?' "
The settings on Cedars-Sinai Medical Center's three CT scanners were changed, causing "immediate jeopardy" in a case that the hospital says involved more than 200 patients who underwent stroke imaging between February 2008 and September 2009, according to a report released last week by investigating California health officials.
The report said that "on or about February 2008, the scanning parameters of three CT Scanners were changed from the manufacturer's recommended output of 80 kv (the amount of voltage delivered) and 200 mA, (milliampere, the duration of the exposure) to 120 kv and 'automatic,' meaning the machine determined mA (usually in the 500 mA range)."
State officials reported that an employee told them "the reason for the change in radiation output of the machines had not been determined, nor had the person(s) who performed or authorized the radiation output changes identified.
Another employee reported that "50 rads (units of radiation exposure-radiation absorbed dose) had been projected to be the dosage to the patients prior to February 2008 for patients undergoing the CT Perfusion Brain Scan procedure. The increased machine settings were calibrated to deliver approximately 7 times the former radiation level."
In a statement last week, hospital officials said they have implemented new policies and procedures. The hospital's plan of correction to prevent future overexposures has been approved by the state.
However, who is to blame for the mishap remains unclear. Hospital officials previously said they did not want to shift responsibility for the incident to the CT scanner's manufacturer, General Electric.
But in its statement last week, Cedars-Sinai officials said the incident "has raised considerable questions about why the manufacturer-set 'auto' mA setting for the brain perfusion CT scan delivered a higher than expected level of X-ray radiation, since 'auto' mA settings in CT and other imaging scanners are generally designed to provide the lowest appropriate level of X-ray radiation."
Cedars-Sinai added the hospital was not the first in Los Angeles that experienced the problem, referring to Glendale Adventist Medical Center.
"On Nov. 20, a second hospital in Los Angeles County reported a similar problem with GE brain perfusion CT scan equipment where patients received higher than expected levels of X-ray radiation," according to Cedars-Sinai's statement.
"Over the past weeks, Cedars-Sinai has received calls from other institutions asking about the incident to learn what procedures Cedars-Sinai has put in place," according to the hospital. "As a result, in its cover letter to the California Department of Public Health, Cedars-Sinai also encouraged the agency to share with other healthcare providers the agency's expectations about policies and procedures to track and trend brain perfusion CT exposure data."
In a statement from GE, the company noted: "Due to pending litigation, we cannot comment on that, but again, there were no malfunctions or defects in any of the GE Healthcare equipment involved in the Cedars incident."
Regarding the case in Glendale, however, GE wrote, "GE Healthcare is concerned for the health of patients who may have received excess medical radiation at Glendale Adventist Medical Center. We are helping the hospital with its investigation, and have sent GE's top CT experts to the Glendale facility where the equipment is located. Knowing that patient safety is the primary concern of Glendale Adventist Medical Center, GE Healthcare will continue to provide its full support to ensure all steps are taken to prevent similar incidents.
"Although this investigation remains ongoing, GE has not learned of any equipment malfunction or problems with GE protocols provided with the CT scanner," GE added.
New details about overdoses
The state's report gives previously unpublicized details about how the radiation overdoses came to light.
During state investigators' interviews with hospital employees, "it was revealed that Patient 2 contacted Employee 3 to 'inquire about hair loss,' through her ex-husband, a staff physician at the facility," after she had undergone the brain perfusion CT.
"On 8/13/09, Patient 2 met with Employee 3 to discuss the concern. On 8/18/09, Employee 6 telephoned Patient 2 to inform her that the case of the hair loss could not be determined.
"On 9/22/09, Employee 6 spoke with Patient 2 to inform her 'she had received enough radiation to lose her hair.' "
In last week's state report, investigators said the Los Angeles hospital's "failure to develop a written policy/procedure to track, trend, and provide oversight of the CT Brain perfusion protocol exposure data, is a deficiency that has caused, or is likely to cause, serious injury or death to the patient, and therefore constitutes an immediate jeopardy within the meaning of" state health and safety codes.
The classification of the event as one involving "immediate jeopardy" means the hospital may be subjected to state-imposed fines of $25,000 to $50,000. Hospital officials have said that about 40% of 260 patients who received doses of radiation either had patches of hair fall out or redness of skin.
Cedars-Sinai officials also have said that the additional radiation exposure may have made patients more susceptible to cataracts. The hospital has volunteered to pay for any medical expenses caused by conditions related to their overexposures.
When the Senate returns today to start debate on its healthcare reform bill, one group of medical providers likely to be taking sharp interest in the proceedings are those providing cosmetic surgery and related medical procedures.
Under a provision (Section 9017) inserted in the bill released earlier this month, a 5% tax has been proposed on the elective cosmetic procedures.
This tax, which quickly earned the nickname "bo-tax" in the media, is expected to raise about $6 billion of the projected $849 billion cost of the bill over the next decade. This tax would be paid by patients receiving the procedure or treatment and then collected by physicians. The tax, though, is to be paid whether or not the services are reimbursed by insurance.
The tax, as specified in the bill, would not apply to cosmetic surgery to correct congenital deformities or disfigurements resulting from an accident, personal injury or disease. However, representatives of cosmetic and plastic surgery organizations have quickly moved to point out that the others are not all necessarily "Cadillac" or high-cost procedures performed just for a wealthy clientele.
"This tax is effectively a 'Soccer Mom' tax that will adversely impact mainstream American wives and mothers, who are the majority of plastic surgery patients," said Renato Saltz, MD, president of the American Society for Aesthetic Plastic Surgery.
A survey from the American Society of Plastic Surgeons of people planning to have cosmetic surgery within the next two years found that 60% of respondents reported an annual household income of between $30,000 to $90,000 a year. In addition, 40% of those reported a household income of only $30,000 to $60,000; only 10% of respondents reported a household income of more than $90,000.
"Medical professionals in the cosmetic surgery industry object to this tax provision because it doesn’t really reach the wealthy as intended," said Jeffrey Raval, MD, a Denver facial plastic surgeon.
Providers also have been critical of the definition of "cosmetic" as applied to the tax—saying the language was adapted from Internal Revenue Service rules currently in place to bar tax deductions for elective and cosmetic procedures. The interpretation could be tricky in determining if breast reconstruction surgery, for instance, qualifies for the tax—when the treatment of the disease caused the disfigurement, Ravel said.
According to the ASPS, the only tax on cosmetic medical procedures imposed among the states has been a 6% tax in New Jersey. ASPS said early indications are that the state has realized a 59% shortfall based on projected revenue estimates since the legislature passed the measure in 2004. At least six other states—Texas, Illinois, Washington, Arkansas, Tennessee, and New York—have had "Bo-tax bills" introduced, but none of them have actually passed.
ASPS also noted that in 2008, 12 million cosmetic plastic surgery procedures would have been subject to the tax performed nationwide—a 3% increase from 2007. Of those, 1.7 million were surgical procedures, with breast augmentations (307,000 procedures; down 12% from 2007), nose reshaping (279,000 procedures, down 2%), liposuction (245,000 procedures, down 19%), eyelid surgery (221,000 procedures, down 8%), and tummy tucks (122,000 procedures, down 18%).
Approximately 4.9 million reconstructive procedures were performed last year, including tumor removal, laceration repair, scar revision, hand surgery, and breast reduction, the ASPS said. This category rose 3% from 2007 tallies.
The Senate is set to begin debate on its health-overhaul bill, with Democrats and Republicans planning to offer amendments on divisive subjects such as abortion and taxes that could hamper passage of the bill. The debate is expected to last at least several weeks. Democrats would like to pass a bill by Christmas, but have yet to find a formula that can win 60 votes, the number required to conclude debate. Lawmakers from both parties are planning to introduce dozens of amendments, addressing issues from a government-run healthcare plan to medical malpractice lawsuits to abortion and taxes, the Wall Street Journal reports.
Measured against the promises President Obama and congressional Democrats have made about healthcare reform, the bill the Senate begins debating this week could be setting Americans up for disappointment, the Washington Post reports. Some of the main reforms would not take place for several years, and even when they do, some observers say, the bill does too little to make sure they would be enforced, the Post reports.
Experts remain deeply divided over whether healthcare legislation would rein in soaring healthcare costs or simply add millions of people to a system that is already driving the nation toward bankruptcy, the Washington Post reports. Optimists say the $848 billion package drafted by Senate Majority Leader Harry M. Reid (D-NV) contains promising ideas for transforming the healthcare system and encouraging doctors and hospitals to work more efficiently. They say it would eventually reduce both private premiums and the swelling cost of government healthcare for the elderly and poor. But opponents see scant evidence that those ideas would quickly bear fruit, and in the short term they fear that the initiative would leave Washington struggling to pay for a new $200 billion-a-year health program even as existing programs require vast infusions of cash to care for the aging population, the Post reports.
A handful of Democratic senators are pushing to change pending healthcare legislation so that it would help increase the country's stock of primary-care doctors due to warnings that the bill may exacerbate the difficulty some Americans already have in finding a doctor. More than 30 million Americans would get health insurance under the healthcare overhaul that passed through the House and a similar bill moving forward in the Senate. If that happens, many previously uninsured people who haven't had a regular doctor before will need a primary-care physician. But pressure to keep down the legislation's cost led Democrats to exclude one way of alleviating the projected physician shortage, the Wall Street Journal reports.
