Officials of outpatient centers say they provide personal care in a less stressful environment than hospitals and the procedures are less costly. It has become increasingly common for women to have breast reduction surgery at an outpatient surgery center.
Hospital leaders insist there are questions about the ethics of some of the outpatient programs and their reliability.
"We are at risk of blurring the line between commercial businesspeople and medically ethical doctors," says Terry Myckatyn, MD, director of breast and cosmetic plastic surgery at the Washington University School of Medicine in St. Louis. Too often, providers are offering Botox and other cosmetic procedures that are not regulated by national plastic surgery organizations, he says.
The dispute has been ongoing for years, with patient care and economics at the crossroads.
Concerns over improper practices in plastic surgery clinics have prompted some states to crack down on such outpatient programs. A series of deaths prompted Florida officials years ago to require plastic surgeons to have proper board certification to ensure they have the proper training.
More recently, reports in Virginia about patients seriously injured during outpatient cosmetic procedures done by those without board certification prompted the Virginia Board of Medicine to recommend a crackdown.
But even accredited outpatient facilities and hospitals have stepped up competition, and are raising questions over some clinics' competencies.
Those disputes prompted Grant Stevens, MD, medical director for Marina Plastic Surgery Associates, a Beverly Hills, CA, outpatient facility, to conduct an extensive study of breast reduction procedures at outpatient and hospital facilities. He says his 11-year study of breast reduction procedures of more than 400 patients at his center showed they can be accomplished as safety as a hospital. The report, published in the Aesthetic Surgery Journal, supported the "safety and efficacy of outpatient reduction mammoplasty performed inan accredited facility."
Stevens said it was important to show that there were similarities between accredited outpatient facilities as well as hospitals for patients as well as physicians. "For various reasons a number of people were reluctant to do outpatient procedures," he says. "But we found there was no downside and a huge cost savings."
This article appears in the April 2012 issue of HealthLeaders magazine.
This article appears in the April 2012 issue of HealthLeaders magazine.
In healthcare, the plastic surgery business is more than skin deep, but not wrinkle free.
Cosmetic plastic surgery is often tied to the variables of economic trends, but some hospital officials are seeing an uptick in certain procedures. Patients are opting for more facelifts and eyelid surgeries. And they are seeking more of the lower-cost procedures such as chemical peels, Botox, and "fillers" to get the shape and proportion of faces, noses, and breasts they want, even if it is temporary.
Plastic surgery for medical purposes continues to advance. Breast reconstruction surgery is increasing—by at least 8% in 2010, with many instances linked to cancer cases, according to the American Society of Plastic Surgeons. The 2011 American College of Surgeons reported that the number of women undergoing breast reconstruction procedures doubled between 1998 and 2007.
Overall, there were 13.8 million cosmetic procedures (surgical and minimally invasive) in 2011, up 5% since 2010, and 5.5 million reconstructive plastic surgeries in 2011, up 5% over 2010.
Hospitals that have offered a wide range of multidisciplinary programs related to cosmetic as well as medical procedures are seeing increased patient load.
"We have seen a significant increase in our breast reconstruction annually," says Rod J. Rohrich, MD, chair of the department of plastic surgery at the 424-bed University of Texas Southwestern Medical Center in Dallas, which reported an overall 10% increase in plastic surgery procedures over the past several years.
As for cosmetic procedures, they are "self-pay, and obviously that’s waxed and waned over the years," Rohrich says. "I still think patients want to look as good as they feel. If they don’t want to pay for major procedures, they’ll resort to more temporizing and cost-effective fillers like Botox, which will make them look good but not be as costly or as permanent as a facelift."
For its breast cancer patients especially, UT Southwestern’s Harold C. Simmons Comprehensive Cancer Center specializes in a multidisciplinary approach for its plastic surgery program that relies on partnerships with oncologists, radiation oncologists, and breast imagers in the same facility, Rohrich says. As part of its specialty care, the hospital targets patients with a family history of breast cancer or high-risk benign breast conditions, using a comprehensive risk counseling program developed at UT Southwestern.
To generate more ROI, UT Southwestern built what hospital officials described as a four-star hotel for patients, bringing them from around the world, whether it be for facial rejuvenation or body and breast contouring. The UT Southwestern campus includes a 21,000-square-foot outpatient surgical facility as well as Medallion Guest Suites, which are available for patients resting and recovering from treatment or surgery.
The suites have "contributed to our ability to attract patients from around the globe with the concept of comprehensive, private, and safe patient care in a protected environment that is not in a hospital setting," Rohrich says.
James E. Zins, MD, chairman of the department of plastic surgery at the 1,300-bed Cleveland Clinic, says hospitals that have developed service lines in plastic surgery have optimized care and outcomes by having both medical and cosmetic programs.
Zins recalls that several years ago, private practice plastic surgeons began sustaining financial reverses from a decline in cosmetic surgeries, which was "very frightening to the private practice cosmetic surgeon."
But systems such as Cleveland Clinic were able to weather recessionary storms in plastic surgery by maintaining cosmetic and medical options through reconstructive surgery, including dermatology and facial plastic surgery. "If the hospital was just doing cosmetic surgery, it would be in big trouble," Zins says. "Our department, for instance, is big and diverse enough that the downturn wasn’t a big hit on us. Now, as it is, noninvasive procedures like Botox and fillers are going up dramatically."
While the number of cosmetic surgeries has been uneven in recent years, often dependent on economic factors, medical procedures in plastic surgery continue to increase, says Andrew Winkler, MD, assistant professor and director of the Visage Center, a facial plastic surgery practice run by the 437-bed University of Colorado Hospital in Aurora. A plastic surgery service line draws patients who like the prospect of a program supported by the depth of medical care, adds Winkler. "For a hospital, it’s important to provide the full service to the community. We want to provide every kind of service. Plastic surgery is that service."
Some hospital systems aren’t eager to develop a plastic surgery service line, but instead keep the programs within specific service lines such as oncology, concentrating on reconstructive rather than cosmetic surgery. "It’s very competitive; you are competing with a lot of outpatient centers," says Marcia Manker, CEO of the 218-staffed-bed Orange Coast Memorial Medical Center in Fountain Valley, CA, referring to hospital-run plastic surgery centers. As opposed to reconstructive surgery, which is typically covered by health plans, cosmetic surgery is "a cash-based program very susceptible to economic forces and very price contrived," she says.
Success key No. 1: Increasing awareness, increasing ROI
For greater ROI and improved patient outcomes, hospitals rely on breast reconstruction surgery following oncological procedures. Hospital systems, however, are concerned that they aren’t doing enough to get the message across about the availability of reconstructive surgery following a lumpectomy, or partial removal of the breast. If they do get the message across, there would be greater ROI for the hospitals as well as increased satisfaction for the patients, says Terry Myckatyn, MD, director of breast and cosmetic plastic surgery at the Washington University School of Medicine in St. Louis.
Breast cancer is one of the leading causes of cancer-related deaths, with 80% of breast cancers treated for breast conservation therapy such as a lumpectomy. Congress guaranteed universal coverage for breast reconstruction after cancer surgery in 1998, but nationally only 30%–40% of women who had mastectomies now receive breast reconstruction.
At Barnes-Jewish Hospital in St. Louis, where Myckatyn sees patients, about "70% of our patients who undergo mastectomy will have a reconstruction surgery, which is well above the national average," he says. The hospital attributes the tally to the hospital’s relationship with primary care physicians, as well as education programs.
"What dictates a patient having the surgery is referrals from a physician," Myckatyn says. "You can be in a referral pattern that detects more mammograms and detects more breast cancer. We are the downstream effect, basically, from that pattern."
Ultimately, "this is a complex procedure that requires more buy-in on the patient’s part," he adds.
State governments are taking steps to improve education about breast reconstruction. In New York, for instance, a law requires doctors and hospitals to discuss options for breast reconstruction with their patients before performing cancer surgery, to explain insurance coverage information, and to refer them to another hospital, if necessary, for reconstructive surgery, Myckatyn says.
Only now has the hospital begun to evaluate patient satisfaction scores related to plastic surgery and breast reconstruction.
"This is an area that has not been well studied largely because there is a lack of validated instruments to measure post-surgical satisfaction," Myckatyn says.
Success key No. 2: Growing interest among elderly
Increasing numbers of geriatric patients are becoming the focus of primary care physicians. And now plastic surgeons.
Indeed, health systems are seeing people with healthier lifestyles who seek to maintain a youthful appearance, says Zins, chairman of the department of plastic surgery at Cleveland Clinic.
About 40% of the population over the age of 65—which amounts to more than 12 million Americans—is likely to undergo plastic surgery, and their numbers may increase. Zins says he carried out a plastic surgery study that shows physical condition rather than chronological age impacts circumstances of people over 65 years old. Older Americans are seeking plastic surgery, in part, to appear younger for personal or professional reasons.
"Patients 65 and older represent an increase in percentage of patients seeking cosmetic surgery and represent a source of increase in patient volume," Zins says.
In 2010, there were 54,885 surgical procedures among patients aged 65 and older. That included facelifts, cosmetic eyelid operations, liposuction, breast reductions, forehead lifts, breast lifts, and breast augmentations. Those numbers represented a 352% increase over 1997 levels, according to the American Society for Aesthetic Plastic Surgery.
Zins says that age lone isn’t a risk factor for plastic surgery.
Zins found that patients who undergo a facelift after age 65 are at no higher risk of complications compared to younger adults, depending on proper screenings. In a review of facelifts of more than 200 people over a three-year period, Zins found no statistical difference in complications between the older and younger patients. One group had an average age of 70; the other was 57.6.
It is important that elderly patients are thoroughly screened, he says. In the study, the patients were screened for problems such as lung and heart disease, diabetes, and high blood pressure, as well as use of medications such as anticoagulants, he says.
Success key No.3: Reorganization and cohesive communication
Several years ago, Cleveland Clinic found inefficiencies in the manner in which it organized and generated plastic surgery procedures.
Throughout the campus, plastic surgeons were spread out. Cosmetic surgery was done by plastic surgeons and other subspecialists, and they were competing and duplicating services. The process lacked communication and coordination, says Zins.
"You could get different prices. You could get duplication of services, personnel, equipment, and operating rooms," Zins says. "We got together and looked at all the advances from a multidisciplinary approach. Rather than compete, we organized and began working together to connect the patient with the best person to do the procedure."
The hospital staff has become "verticalized," as each plastic surgeon has an area of clinical focus within the Cleveland Clinic departments of dermatology and plastic surgery, he says. The department of plastic surgery, which includes 17 plastic surgeons, focuses on areas including facial cosmetic surgery, cosmetic and reconstructive breast surgery, and body contouring. Plastic surgery centers have been situated in suburban outpatient facilities to create greater access for patients. "What we have done has become a tremendous opportunity for the patient," Zins says. "We want to provide convenience for the patient, and avoid any possible delay to their busy schedule."
The Cleveland Clinic also has taken steps to plan for a video conferencing program that would allow patients from anywhere in the country to evaluate possible plastic surgery procedures, he adds.
Success key No.4: Rhinoplasty
Cosmetic procedures in plastic surgery often shift and depend on changing economic conditions, with overall procedures increasing since 2008, primarily due to noninvasive and less costly options such as Botox treatments.
"For some reason, human beings are more tolerant of aging changes in times of down economy," says Winkler. However, he adds, "Rhinoplasty hasn’t been hit as hard as other cosmetic surgery procedures."
Of the costly functional procedures, rhinoplasty "seems to be the only surgical procedure that’s recession proof because parts of the procedure are paid by insurance companies," Winkler says. In the plastic surgery world, rhinoplasty means income for health systems because of its unique appeal, he says.
"It straddles the line between cosmetic and functional. People may need surgery to breathe through their nose, but would like cosmetic changes done as well. Many people have functional problems that need to be fixed and figure it’s a good time to have cosmetic concerns addressed."
Clinically, rhinoplasty is directed toward improving nasal breathing disorders and nasal skin cancer reconstruction. Cosmetically, the procedure is designed to reshape a patient’s nose.
Winkler explains that "although people are still spending money on cosmetic procedures, they are spending it on the clinic-based, temporary and less-expensive ones. I would estimate that about 20% of the surgeries that I do are cosmetic in whole or part—meaning the patient is paying out of pocket."
In the past, Winkler says, "those in my position would do a great deal more cosmetic work. I know from personal communication with colleagues who have been in this business for 10 to 20 years who are doing roughly half as much flat-fee cosmetic work as they were five years ago, before the housing crash."
This article appears in the April 2012 issue of HealthLeaders magazine.
I'm just starting this column and already I'm saying, "I'm sorry."
A year ago, I wrote how the University of Michigan Health System found it extremely worthwhile in cost savings and patient satisfaction when physicians apologized for doing something wrong.
I'm bringing it up again, and I'm sorry for repeating myself, but there's much more to say about this now.
In medical cases, apologies don't make the malpractice issue go away, nor do they necessarily prevent such litigation. I'm writing about this simple practice again because other, similar efforts are worth spotlighting in their attempts to reduce malpractice litigation, not only through scattered health systems across the country, but on a statewide stage.
For instance, the Massachusetts Medical Society last month announced plans for a pilot program involving hospitals, physicians, academics and insurers to use an approach of "Disclosure, Apology and Offer" to reform the medical liability system in the Bay State.
The DA&O refers to when physicians admit mistakes, offer an apology, and potentially offer to settle the issue, not necessarily in court. The program was initiated after the society released a report, Roadmap to Reform, which focused on exploring alternative approaches to the existing tort system involving medical liability.
The society and the Beth Israel Deaconess Medical Center received a grant from the Agency for Healthcare Research and Quality to undertake a three-year pilot of this initiative.
The seven hospitals participating in the program include three from the Beth Israel Deaconess Medical Center system, based in Boston, three from the Baystate Health System in Springfield, MA; and Massachusetts General Hospital.
"We're proposing a fundamental transformation of the medical liability system to use the courts as a last resort," says Alan Woodward, MD, past president of the Massachusetts Medical Society, who is involved in the project. "We know the current liability system is driving unnecessary costs in the form of defensive medicine. If you are going to get serious about healthcare costs, you are going to have to deal with defensive medicine." Eventually, Woodward says, the group may seek legislation to overhaul state as well as national policies.
The aura of litigation "intimidates people so they aren't open to discussions," Woodward adds. "Lawyers have told physicians for decades, ‘If something goes wrong, don't talk to anybody but me.'"
The Massachusetts Medical Society's DA&O plan says it offers patients "a full disclosure of what happened and why (and what will be done to prevent a recurrence of the event), and for events deemed avoidable, a sincere apology and appropriate and timely offer of compensation. It won't deny patients the right to bring legal action, but would make tort claims a last resort."
The University of Michigan Health System's "apology" program has been seen as a benchmark among those seeking to establish similar programs. The health system adopted a policy of investigating adverse events in 2002, which included the apology strategy. Using the technique over the past decade, the health system has been "incredibly successful by all the metrics," Woodward says. It has reduced the length of cases, and the administrative costs of each case by more than 60%, he adds. "There has been tremendous satisfaction on the part of physicians and even attorneys," according to Woodward.
Although there have been many organizations that have initiated the apology strategy, many physicians, obviously, don't use it. "Patients never get an apology," Woodward says. "It is something they look for. When something goes wrong, there's almost a termination of open communication between physician and patient."
A Massachusetts Medical Society study showed that there is strong support for the DA&O approach because, among other things, it is the "right thing to do" ethically, according to Woodward.
The Massachusetts hospitals, physicians, patient groups, and insurers who are carrying out the pilot want to take the University of Michigan Health System work even further by applying it to the entire state.
"What we are doing now is taking that model that has been very successful at the University of Michigan Health System, at Stanford and numerous other hospital systems across the country, and we're saying, ‘why don't we implement this as a statewide model?" Woodward says. "That's what makes this different."
What's also different is that Massachusetts Medical Society officials plan to help hospitals involved in the pilot program on a day-to-day basis when confronting potential malpractice situations. The society is working with physicians who may have experienced malpractice litigation themselves and can serve as mentors to other physicians, he adds.
"A mentor would be someone with a greater breadth of experience or [someone who] has gone through this themselves, who can help the clinician prepare to have a dialogue with a patient," Woodward says. When physicians discuss mistakes with patients, they can "always make the situation worse, if they make people feel worse rather than better."
In addition, the program is establishing a blog and a research system with data to support physicians. Education programs are vital, Woodward says, because "very few physicians know how to do this," referring to the apology technique.
Barriers to overcoming medical liability reform are included in the Massachusetts Medical Society's Roadmap to Reform. Among the roadblocks the report cites is physician discomfort with disclosure of errors.
But it's that very thing—admitting a mistake and saying "I'm sorry"—that's a first step towards the reform so many are seeking.
The Caring for Women, PA obstetric and gynecologic practice in Denton, TX, helps newborns begin smoothly in life, but the physician group itself is struggling to survive.
The small practice faces constant fiscal challenges and has made cutbacks to salaries and retirement benefits amid worries that the physician group may be nearing its end. The Caring for Women practice's difficulties reflect those faced by small physician groups across the country who wonder whether they should join bigger, high volume groups, or even get out of the caring for people business altogether.
The practice is not comprised of grizzled veterans who have seen enough and are ready to make a change. Rather, these are physicians who only started out in the 1990s, and are thinking of bailing out already.
Joseph S. Valenti, MD, FACOG, one of four practicing doctors in the group, handles the administrative duties for the organization, which also includes three midwives, a nurse practitioner, and other staff.
Now in his early 40s, Valenti easily lists why he and his colleagues are reconsidering the future of the practice. "My income in the last five years has gone down 33%, and my overhead has gone up 50% every year," Valenti tells HealthLeaders Media.
"The physicians in the group decided to take a pay cut. The physicians also took almost $80,000 out of their own retirement fund. It's a challenge to find more places we can cut, still keep good people in the office, and see patients appropriately. It's becoming harder and harder."
Facing uncertainty, Valenti's somewhat pessimistic attitude about his future mirrors the view of many young physicians. Last month, a survey of 500 doctors by The Physicians Foundation showed that 57% were pessimistic about the future, with 30% saying they were "highly pessimistic," citing the new healthcare law or regulations as key reasons for their discontent.
Unlike Valenti, as many as 80% of doctors surveyed expressed satisfaction with their current arrangements, with 35% saying they are highly satisfied. At least 39% say they aspire to some form of ownership position in the future, either as a sole owner or partner.
The typical survey respondent was an employee of a medical group. When asked about the Affordable Care Act, 49% said they believe the impact on their practice will be negative, and 23% anticipate that it will be positive.
About 27% of the physicians surveyed say they are changing or considering changing their practice or employment arrangements over the next year because of "financial issues."
Lou Goodman, president of the Foundation, says he was surprised and troubled by the findings that young physicians are so disgruntled about what they believe the future holds in their profession—especially since people are applying to medical schools in record numbers.
The number of applicants applying to U.S. medical schools was 43,919 and reached an all-time high in 2011, according to the Association of Medical Colleges.
"There are more applicants than ever," Goodman says. "So people are very excited about medicine; it's still the best and the brightest. It's a huge investment of time and a $200,000 plus debt. But they have these unmet expectations. Their expectation is, 'I've gone through this, I am a trained practitioner, yet I don't have the opportunity I want. There is this bombardment of regulations."
Reluctance toward hospital employment The survey also shows perceived reluctance among young doctors about hospital employment. While 31% of the hospital-based respondents are employees of a larger group, only 12% would prefer such an arrangement, and they say they are more likely to spend two years or less working at a hospital. Most medical surgical office-based physicians say they would spend up to eight years or more at those positions.
That doesn't bode well for hospitals, Goodman says. The young physicians may feel they have more opportunities to work in a hospital, but feel "that is something I want to do on a short-term basis, and I'd rather work with other doctors in a collegial relationship."
"By saying they want to stay only two years in a hospital, what are the implications of that for a patient?" Goodman asked. "We have said for years that we need continuity of care, and make sure care is accessible and affordable, but I think this is contrary to what people are seeking. And if these doctors are pessimistic, and they have gone through all this incredible training and feel their expectations are not being met, we have a national problem. Already, we have a shortage of 150,000 primary care physicians, and then we will have 30 million more (insured patients) from the Affordable Care Act. We will need more doctors. Whether this is a passing attitude, or because of this particular time in our history, I don't know, but I'm very surprised at the level of pessimism."
Oddly enough, the survey findings fly in the face of what some hospital officials are reporting about young physicians. Indeed, many physicians and hospital leaders I've spoken to are optimistic about the attitudes of young physicians.
For one thing, in hospitals, many are likely candidates for multidisciplinary approaches, more suitable for team-based care that is being promulgated throughout healthcare. And many of these physicians may have less of an inclination toward burnout in their work habits, in part, because they don't want to work all those crazy hours they observed their older compatriots working. It's important to the younger doctors to have "a life."
Valenti, the Texas physician, says he understands why many of the young physicians are disgruntled, as he is, and he's surprised there aren't more. But Valenti, who volunteers for the Physician Foundation, and his colleagues aren't giving up their practice without a fight.
Recently, the practice opened its doors earlier and kept open the lunch hour to serve more patients. "To keep our practice alive, we varied our hours to accommodate patients more, [that's] one of the things we are doing to stay afloat as a private practice," Valenti says.
In the meantime, the physicians are going to meet with insurers and discuss reimbursements, Valenti adds. "We are going to the pull out our data and show we're doing as good as we can, and we do a great job with patients," he adds.
If the group doesn't make headway to improve its financial situation, "we're going to look at the administrative cost of joining a group that has better contracts than we do. I don't know what else to do,"
Valenti is a young doctor, but the profession has gotten him older.
"There was a time I felt a little bit sad and angry," Valenti says, "And now I feel determined."
When you're a hospital infection prevention and control official, sometimes talk around the dinner table isn't about patients, but about what to do before greeting them, like washing your hands.
"Don't they all wash their hands?" Barbara Russell, RN, MPH, CIC, director of infection control at Baptist Health of Miami, FL, recalled her mother asking.
Well, many do, but not all.
Russell talks about her job as an infection prevention and control official as being akin, in part, to being the "handwashing police," (my words, not hers). And when she and her like-minded colleagues confront some co-workers who haven't washed their hands, they are "polite," (her words, not mine).
A major focus is to ensure hospitals have plans in place to stop infections, including the simple task of hand washing. But who monitors the infection prevention officials?
Beyond Handwashing
Russell says one of the best things a hospital can do to improve infection control monitoring is to hire a certified infection prevention official, as she is.
Most are nurses, but the category also includes microbiologists and physicians. Certification requires up to two years of training about infection control.
A recent study in California showed that only 89 of 174 control directors, about half, were certified in infection control, which suggests that evaluations of infections may not be as good as they should be.
Russell estimates that about one-third of hospitals nationwide have certified infection prevention officials. "It's like having a certified cardiologist or internist; it shows [that] this person is not the new kid on the block, but someone who has really delved into the issue and knows it," Russell says. "By being part of such a group, you are able to learn from each other and share what you are doing, or have done, to reduce (infection) rates—which another participant could also try."
The study in question was published in the March issue of the American Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology.
"We found that having an infection control director certified in infection prevention was associated with lower rates of MRSA bloodstream infections," Monika Pogorzelska, PhD, MPH, told HealthLeaders Media. She is associate research scientist, P-NICER study director at the Columbia University School of Nursing and a co-author of the study.
Digging Into the Stats
While news releases touted the "significantly" lower rates associated with the certified infection control directors, they did not mention the exact rates. I asked Pogorzelska why not. She told me her study found that the "presence of an infection control director certified in infection control has .3 times lower MRSA infection rates compared to hospitals that did not have a certified infection control director."
So, that's like a batting average of .300—a 30% success rate, correct?
No, not really. "It's a bit of a weird statistic, so I can't easily turn it into a percentage," Pogorzelska said, but she added that "this association was statistically significant."
After I asked her again, Pogorzelska said she would revisit the numbers and try to find a percentage.
A few minutes later, she emailed me. Bingo.
"I double checked with my statistician on the correct interpretation in terms of percentages and it is about a 78% reduction in terms of rates."
Wow.
So, indeed, there is a significant impact on MRSA that is associated with having certified infection control officers in hospitals. But in this day of multidisciplinary teams in health care, it's not up to the infection control specialists alone to do the job, Pogorzelska says.
Infection Prevention a Team Effort
"It is clear that infection prevention is a team effort and all clinicians and personnel need to be working together to prevent infections," Pogorzelska says. In essence, a "multidisciplinary team of qualified professionals that work together is needed to implement prevent strategies appropriately."
The study found that 97 percent of the hospitals surveyed performed some type of screening upon patient admission, especially for MRSA. By contrast, few hospitals reported the use of universal and targeted screening for two other multidrug-resistant organisms: vancomycin-resistant Enterococcus (VRE) and Clostridium difficile (C. difficile).
One major reason for this focus on MRSA is legislative requirements in California for these screening programs, but Pogorzelska says the "level of specification on one type" of pathogen may limit the ability to address others like VRE and C. difficile.
Some organizations are forming interdisciplinary task forces and successfully decreasing C. diff incidence by developing specific cleaning protocols after observing staff cleaning routines. The Hunterdon Medical Center in Flemington NJ established a task force that launched protocols that revised existing cleaning protocols.
For physicians, nurses and other hospital workers, the possibility of infection is always there.
"Whether a hospital uses universal contact precautions or universal MRSA screening, or some combination of interventions—infection prevention strategies need to be carried out by all personnel at the bedside at all times," she says.
"Follow the money," suggested Deep Throat, the source Washington Post reporter Bob Woodward consulted during the Watergate scandal in the 1970s, as the journalist tried to understand the Nixon administration's covert activities.
Today, that same advice applies if you're trying to figure out why some physicians might be ordering too many tests and procedures.
Over-ordering tests has been an issue for years in many aspects of healthcare. It's been investigated by outside agencies and continues to be—with one of the primary questions involving self-referral. The term "self-referral" describes arrangements in which a physician refers a patient to a healthcare facility in which the physician has a financial interest. Self-referrals can be considered legitimate, because of what many consider a loophole in the law.
Suspicious Physicians
Sometimes though, docs themselves get suspicious and upset when they see too much money being funneled to their colleagues or competitors.
That's how a number of urologist groups have been feeling as word spreads that some of their colleagues have been getting a lot of money by self-referral arrangements between urologists and pathology groups. The result? Too many tests, too many evaluations and money too easily made. It was all too convenient, too cozy, too much of an opening for abuse of the system.
With the publication of an article in Health Affairs this month, concerned urologists now feel that they have some added proof with which to persuade Congress that the loophole needs to be closed.
The Health Affairs study focused on self-referral among urologists who conduct prostate biopsy evaluations in their own pathology labs. It found that urologists involved in self-referral arrangements bill Medicare 72% more for specimen evaluations for patients who have suspected prostate cancer than urologists who send specimens to independent providers of pathology services.
More Billing, Less Detection
Oddly enough, despite the increased billing, the study found that self-referring urologists usually detect cancer at a much lower rate—about 57%—than do non-self-referring urologists, according to the study's author, Jean Mitchell, PhD, an economist at Georgetown University in Washington D.C.
The study findings show that "lower cancer detection rates linked to self-referring urologists suggest that financial incentives prompt those urologists to perform prostate biopsies on marginal cases," Mitchell writes. "Thus, self-referral of prostate surgical pathology services leads to increased use and higher Medicare spending, but lower cancer detection rates."
The Loophole
Mitchell says it's time that the government closes loopholes that enable some self-referral. Although there are federal and state laws designed to curb self-referral, one of the biggest exceptions refers to "in-office ancillary services," Mitchell says. The exception allows physicians and group practices to self-refer or "in source" certain health services, such as diagnostic imaging, physical therapy and anatomic "pathology."
"The findings support eliminating the exception that permits physicians to self refer patients to in-office pathology laboratories," Mitchell writes in her study. "Both government and commercial insurers could reduce health care spending substantially by adopting measures to restrict self-referral in this context."
"They should close it down; get rid of the loophole," Mitchell tells HealthLeaders Media.
"Get rid of the ancillary services exception and say you can't do it anymore. That exception was in there originally to deal with doctors who do simple blood or urine tests in their office for patient convenience or for the orthopedic surgeon who had an X-ray machine in his office. It was never meant for pathology services where you have to get a biopsy and send it to the lab. What has happened is that the ancillary services exemption allows doctors who aren't trained in one area to basically incorporate the services and practices of physicians in another area into their scope of practice, which is problematic."
"Self-referral is an important concern in health policy because it injects financial self-interest into decisions regarding patient care," Mitchell wrote. She noted that research on advanced imaging shows that self-referral "results in increased use of imaging and escalating healthcare expenses, with little or no benefit to patients."
Mitchell wrote, "Although self-referral for advanced imaging is widespread, the consequences of self-referral on the use of other ancillary services, such as surgical pathology services, has received little attention." She says there is "anecdotal evidence that self-referrals have become increasingly prevalent in recent years."
Mitchell's report adds academic weight to growing concerns about self-referrals. In December 2010, The Wall Street Journalwrote that "groups of urologists across the country have teamed up with radiation oncologists to capture the lucrative reimbursements" of intensity-modulated radiation therapy (IMRT).
The Journal reported that critics of the procedures, including "independent radiation oncologists who are losing business, say the urology groups steer many patients toward IMRT for financial gain," which could include Medicare payments of $40,000 per patient.
Physician groups are reacting to the Mitchell report. The Alliance for Integrity in Medicare, a coalition of medical specialty, laboratory, radiation oncology and medical imaging groups, said it welcomed the study because it provides independent, peer-reviewed evidence that the self-referral practice, in which urologists use their own pathology labs to test prostate biopsies for cancer provides no benefits to patients, and is only serving to drive up Medicare costs.
"There is increasing evidence of self-referral leading to similar inappropriate, unnecessary overutilization of radiation therapy services for prostate cancer patients," said Laura I. Thevenot, of the American Society for Radiation Oncology, one of the sponsors of the study, in a statement.
In the wake of the Mitchell study, it's time that Congress follows the money and closes the self-referral loophole for good.
Go West, academic urologist. You may earn more than $455,000 annually there, compared to $300,000 in the Midwest.
(If you are an academic dermatologist, the Midwest is the place to be, not the West, if you want optimum income.)
Whatever you do in academic circles, if you seek a very nice, comfortable salary, be a department chair and a specialist. Then again, if you are engaged in academia, it isn't all about the money is it? There's more money in private practice, of course, but we'll get to that later.
There's a wide variation in physician-related academic salaries, often dependent on geography and rank within academic settings, says the Academic Practice Compensation and Production Survey for Faculty and Management of 2012. The Medical Group Management Association report, based on 2011 data, contains information on more than 20,000 faculty physicians and non-physician providers categorized by specialty, and more than 2,000 managers.
The salaries also depend upon academic settings, clinical productivity and research support, according to Jonathan Tamir, vice chairman of finance and administration at the Yale University School of Medicine's Department of Internal Medicine.
Department rank, of course, also influences compensation.
While primary care associate professors reported median income of $198,000, primary care department chairs reported a median compensation of $282,296. Specialty care associate professors earned $260,075 and full professors earned $280,000. Specialty care department chairs reported median compensation of $506,200.
Don't expect those income levels to grow much, at least in the near future, Tamir tells HealthLeaders Media. With economic conditions and federal reimbursement changes, "there's a lot of downward pressure on salaries, compensation, and support in general."
"Healthcare is a weird system where you have the usual supply and demand factors at work in some places, but not at work in others," Tamir says. "If you look at medical insurers, they will pay the same amount for services regardless of the tenure and experience of the person doing it. I see salaries increasing marginally. You want to make sure your faculty are not de-motivated by their salaries not keeping up with inflation."
For academic researchers, there have been "negative developments recently," particularly from the government, he says. He referred to reduced support for research, as well as salary reductions. "We're actually seeing mid-term reductions of funding, where someone may be going along and believe they would be funded at a certain amount for five years and then, the government is saying, ‘guess what, we're reducing it,'" Tamir says. "After year three of a grant, the government may say, ‘We're cutting you 10 or 20%.'
"Then, as a researcher, you have to scramble, maybe cut supplies or support staff to produce the results despite the cuts," Tamir says.
Tamir says the government also has placed a salary cap on National Institutes of Health grant research funds. "There are fewer applications being funded, and the physician salaries are being reduced," he says.
While the government may represent a steady erosion of income, physicians face more salary variables from other, "imponderable" sources, such as geography, Tamir says.
In the East, urologists reported $368,401 in median compensation, compared with $300,000 in the Midwest, $336,000 in the South and $445,247 in the West, the MGMA report shows. Tamir says he's unsure why there are such marked differences in urologist pay scales.
Dermatologists in academic settings reported median compensation of $277,765 in the Midwest, and $236,939 in the West. General pediatricians in the East reported $157,289 in median compensation and compared to $139,410 in the South.
When it comes to dermatology, Tamir thinks he has identified factors that explain the salary differences. "Dermatology is clear," he says. "The specialty has a large number of aesthetic procedures that are not covered by insurance and must be paid for in cash," he adds. "Not having to wait for payment and not needing staff to do paperwork is the ideal reimbursement situation."
The MGMA report shows that physician compensation in academic settings is behind that of doctors in private practice, as "is customary," Tamir says. Family practitioners in academic settings reported median compensation of $173,801, compared with $189,402 in private practice.
Specialists in academic settings also were behind physician earnings in private practice, according to the report. Anesthesiologists earned $326,000 in median compensation in academic settings, compared to $407,292 in private practice. General surgeons in academic settings earned $297,260 in median compensation, compared to $343,958 in private practice.
"Salaries in academic practices will always be lower than that of salaries in private practices," Tamir said in a statement. "Physicians in private practices concentrate their effort on providing clinical care to patients, while physicians in academic practices split their efforts between clinical care and research activities. These research activities are never as well compensated as clinical care."
Despite what many people may think, generally "physicians are not going into (the profession) for the money," Tamir says. "If you want to go into big finance, you go to Wall Street and law school, where there's more immediate bang for your buck," he says. "Physicians don't start earning money, for the most part, until they are in their 30s, and they have loans to pay off." There are many years where doctors have to "catch up," he says.
If the downward pressure on physician salaries continues, catching up is bound to take even longer.
By the time the Medical Board of California filed a petition to revoke the license of Michael Jackson's doctor this month—three years after the pop icon died—public complaints were common. Chief among them: What took so long?
It was shortly after Jackson's death that critics started pounding the medical board for failing to quickly revoke physician Conrad Murray's license, or at least seek an interim suspension, after the doctor was charged with illicitly administering anesthesia to the performer, who had wanted to overcome insomnia.
The Jackson case was certainly high-profile, but it is only one of many across the country in which medical boards have failed to act expeditiously, or even at all, against bad doctors.
Earlier this month, a New England investigative reporting group published a story about the Massachusetts Board of Medicine, describing a "veil of secrecy" afforded to some doctors "due to physician-friendly provisions in state law, the board's policy of purging certain records, sometimes in violation of state law, and outdated technology."
Senators call for investigation
In fact, several U.S. Senators last month asked the inspector general of Health and Human Services to investigate the quality of state medical boards in the wake of critical media reports.
Some hospitals are handing medical boards information about bad docs, yet the state boards aren't acting on the knowledge. These do-nothing bodies are betraying patients as well as the hospitals that ferret out wrongdoing on wayward physicians, only to have their findings ignored.
That's the feeling you get after talking to Sidney M. Wolfe, MD, director of Public Citizen's Health Research Group, a consumer health advocacy and lobbying group based in Washington D.C.
"A small number of medical boards are doing a good job. Most are doing a terrible job," Wolfe tells HealthLeaders Media. "Medical boards have been asleep at the wheel too often. Most states are doing a terrible job protecting patients (against) a small number of doctors who are doing damage. One doctor may see 500 or 1,000 patients, but if that doctor shouldn't be practicing, a lot of patients may be injured or killed by that doctor."
Hospitals are filing internal actions banning doctors from their facilities, yet state medical boards, which have the ultimate authority in their jurisdictions, don't act, and these physicians are then free to practice across town.
State-hopping docs
Another issue is state-hopping. Some doctors are disciplined in one state, but they manage to slip unnoticed into another one, even though a national data bank is supposed to alert state officials about sanctioned doctors, Wolfe says.
The situation underscores continued problems with medical boards and their lack of oversight and control, says Wolfe, a veteran voice for better oversight of physicians. He is calling for medical boards to overhaul their structures and improve their leadership to get the job done.
The Federation of State Medical Boards, which represents 70 medical and osteopathic boards in the U.S. and territories, has been working to prevent "doctors hopscotching around the country," says Dan Wood, spokesman for the Medical Board of California. "Doctors do get in trouble and move from one place to another."
Through the federation, state boards "communicate with each other and we're very good at doing that. Some places, like Wyoming or Montana or North Dakota, can move faster on cases, because they don't have the caseload like California. We have been impacted by shortage of people and budget restraints."
Even under the best of circumstances, medical boards have a difficult task. Medical boards often rely on information from the healthcare system, including physician "peers" and "that is the most challenging source of information," says Russ Aims, the chief of staff for the Massachusetts Medical Board.
Some colleagues may simply not want to squeal about a colleague's behavior, he says. "We can't assign [an investigator] over every physician's shoulder." However, Aims says, the board implements education programs and touts the importance of "patient safety and that's what it's all about."
Whether it's because of budget issues or politics, many states aren't moving quickly on doctor discipline cases. An analysis of the National Practitioner Data Bank Public Use File for 1990-2009 found that a total of 10,672 physicians have hospital sanctions, known as clinical privilege actions, against them for improper conduct. As many as 5,887 of these doctors—or 55%—have no pending state licensing actions, however, according to the Public Citizen report.
The hospital clinical privilege actions are peer review orders that Public Citizen says are one of the most important pieces of information used for medical board oversight. But, state board actions against a physician's license provide better assurance that a practitioner would be monitored or limited in work, the organization states.
A Public Citizen analysis says this "raises serious questions about whether state medical boards are responding adequately to hospital disciplinary reports and whether, as required by federal law, state medical boards are receiving such reports."
As a result, many of the doctors disciplined by their hospitals continue to practice unfettered, Wolfe says. "A large number have been thrown off the staff of hospitals and never disciplined," Wolfe adds.
"Part of the reason is that the executive branches of state governments are taking money dedicated to state doctors' licensing fees that are supposed to fund the medical boards and they are using it to try to balance the budgets for the rest of the state's [needs]. That's been going on in a number of states. It means the states are not taking a serious responsibility to discipline doctors who really need to be disciplined."
Wolfe says that Public Citizen has sent letters to state medical boards, urging them to investigate physicians who were disciplined by hospitals for various reasons, but not by the boards themselves.
Of the 5,887 physicians who were disciplined by hospitals between 1990 and 2009:
1,119 were cited for incompetence, negligence or malpractice.
605 had carried out substandard care.
220 were disciplined because they were an "immediate threat to health or safety."
In addition, many of the doctors had a history of medical malpractice payments. A physician in New Mexico had 26 malpractice cases, while a physician in Indiana had 20. Fourteen states had a physician with at least one clinical privilege report, no state licensure action, and at least 10 medical malpractice payments.
The data "demonstrate a remarkable variability in the rates of serious disciplinary actions taken by the state boards. Only one of the nation's 15 most populous states, Ohio, is represented among those 10 states with highest disciplinary rates," according to Public Citizen.
The California state medical board was sharply criticized for failing to act promptly following Michael Jackson's death on June 25, 2009. A judge eventually suspended Murray's license to practice medicine and ordered the state to notify other states where he was licensed about the suspension. Other states where Murray had a medical license, among them Nevada, Hawaii, and Texas, were slow to discipline him too, according to a USC Annenberg School of Communication and Journalism report.
Murray was charged, tried, and convicted of involuntary manslaughter and sentenced to four years in prison before California filed a petition to remove his license.
California officials have defended their actions, saying they were always in touch with prosecutors, and the safety of the public was never at stake.
"We were able to move along at the pace we needed to," says medical board spokesman Wood, referring to the proposed discipline of Murray.
The pace of the states' medical board work involving physician discipline hasn't been good for years. According to Public Citizen "most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner." Without legislative oversight, it says, "many medical boards will continue to perform poorly."
The situation is not without hope, however. State boards can turn their behaviors around, says Wolfe. Most need adequate funding and staffing. They should also have independence from state medical societies, and what they need most of all, says Wolfe, is "excellent leadership" and a board willing to do the right thing.
As the latest HealthLeaders Media intelligence report shows, most healthcare leaders anticipate that their service lines will grow over the next few years, with a big Baby Boomer-fueled push for oncology, orthopedic, and cardiology needs. And younger patients will generate the demand for wellness or neurological care, with new service lines to come.
Yet hospitals shouldn't automatically count on ROI. There's great angst among hospital leaders, the survey shows, in plans to integrate physicians to deliver that bottom line.
HealthLeaders Media Industry Survey 2012 The priorities and concerns of nearly 1,000 of your colleagues in healthcare leadership are revealed in this year's comprehensive multi-part survey, our fourth annual HealthLeaders Media Industry Survey. Download the Free Reports
Indeed, hospital systems are pushing vigorously to capture a burgeoning market with new service lines, from inpatient to outpatient. Over the next two years, 75% of hospitals say they plan on expanding their existing service lines, such as heart and oncology programs, and 50% say they will establish new service lines.
The MemorialCare Health System in Fountain Valley, CA is among the hospital systems exploring various pathways of service lines, not only for the overall system, but for individual hospitals. As the hospital system explores population health and accountable care programs, they are "morphing into larger service lines," depending on the needs and demographics of the communities served, Steve Geidt, CEO of Saddleback Memorial Medical Center in Laguna Hiills, CA. told me recently. He participated in an interview with other members of the MemorialCare system who agreed to address the findings in the intelligence report.
At Saddleback, for instance, hospital leaders are exploring more geriatric and palliative care service lines to address a "very high concentration of very old seniors who are frail," Geidt says. "Our emphasis has been on disease management and end-of-life care."
At the Long Beach Memorial Medical Center, officials are looking into expanding pediatrics, wellness, neurosurgery, and neurology service lines, says Diana Hendel, PharmaD, CEO, of Long Beach Memoriial Medical Center, the Children's Hospital Long Beach and Community Hospital Long Beach.
"As we are transforming healthcare from a more traditional diagnosis and treatment program to include prevention and wellness, expanding those service lines isn't surprising," Hendel says.
Hospitals' push to expand service lines face obstacles in putting together physician teams to accomplish their goals, and in the transition from fee-for-service to value-based care. The intelligence report shows that more than half—54%—of health leaders say it is difficult to attain physician alignment with organizational goals, and 8% say it is very difficult. Along those lines, 41% say it is difficult to develop physician compensation strategies.
As hospital systems work on aligning physicians in service lines, 74% say they are developing standard clinical and operational procedures. But only 35% say they involve physicians in fiscal oversight of organizations. Leaders reveal that their top three service line challenges all involve physicians and finances, the survey shows.
Building physician teams 'not a simple process'
Geidt says he's not surprised by those findings. "It's hard," he says, referring to putting a physician team together for a service line. "It requires a lot of vision, a lot of capital and a lot of energy, " Geidt says. Not only are hospital systems working to improve that physician-hospital integration through electronic medical records, there's the human element. "There's a lot of independent physicians involved, and there's a lot of politics. It's certainly not a simple process," he explains.
Despite Geidt's cautionary comments, MemorialCare Health System's alignment with physicians may be considered relatively smooth compared to other systems, because it has for years incorporated physicians into the process of hospital leadership and service line oversight.
At Memorial Care, a medical foundation and physician society were established to develop physician leadership programs, which have resulted in doctors "getting a true involvement in key decision-making areas, " says Barry Arbuckle, PhD, President and CEO of the MemorialCare Health System and lead advisor for the HealthLeaders Media intelligence report.
The foundation and society help develop clinical guidelines, prioritize technological needs and collaborate in financial and capital planning for the hospital system, Arbuckle explains.
Establishing data programs to help physicians within the system has been a key element in improving protocols, says Hendel, but so has the importance of working on physician relationships with each other and with hospital leadership—areas that other hospital and physician leaders are sometimes too slow to embrace.
"Culture eats strategy for lunch," Hendel says, referring to the importance of people-to-people programs in physician alignment within a hospital system. "We've had a two-pronged effort here," she adds. "We have the data and strategic parts of aligning with physicians, but we've also been sensitive and aware of the cultural alignment aspects, with our physician society leading the way on a shared vision, a shared mission, a shared understanding and involvement where we—as a health system—should be focused."
"That has helped pave the way. We have a lot of work to do, but we have a great basis to start," Hendel says.
This article appears in the February 2012 issue of HealthLeaders magazine.
Changes wrought by technology are making an indelible mark in service lines for health systems big and small. This is being reflected in a hospital when a patient is given an iPod with a Pandora app to listen to any music she wants to hear as she waits for an oncological exam (You want Motown, you've got it!) and in the surgical suite where physicians use da Vinci robotic systems for minimally invasive procedures, as well as new cloud-based data systems that allow clinicians instantaneous access to a patient's heart rhythms.
Health systems are moving ahead quickly in pursuing technology improvements, using robotics, apps, telemedicine, clouds, electronic medical records, device journals, or other innovations to provide value and add volume to their service lines. Leaders of healthcare systems say they are working to improve patient experience and patient flow in highly personalized programs while using smartphones and tablets to monitor health conditions and evaluate symptoms. Part of the rush is based on federal incentives under meaningful use requirements.
Edward W. Marx, senior VP and chief information officer for the 3,800-bed Texas Health Resources system in Dallas, says health systems have little choice but to embark on technological improvements to advance care.
"We work under the strategy that IT exists to transform, grow, and help run the organization and to be viewed as a strategic asset," says Marx. "It's all about patient experience and quality of care. We talk about transforming growth from a business perspective. Innovation is who we are and who we aspire to be. It is pretty much strategic for the organization. We try to live that culture of being innovative, and it expresses itself in many ways."
Texas Health Resources has initiated an array of technological changes that have improved efficiencies and patient care, Marx says. The system has encouraged doctors to use medical apps and smartphones and, on a limited basis, personal health devices such as EKG systems and blood pressure monitors that patients can use at home to help keep them out of hospitals, as well as handheld monitors to ensure they keep appointments.
Health systems are making both tweaks and large-scale improvements to tech initiatives they have had in place for years, such telehealth, EMRs, or robotic programs.
But that doesn't mean all health systems are fully embracing technology just yet. According to the HealthLeaders Media Industry Survey 2012, 20% of leaders say their organization is cutting back on high-level, high-price technology for service lines.
"A lot of hospitals are feeling pressure to get something, and that the technology is going to solve all their problems," says Gregory K. Feld, MD, director of the cardiac electrophysiology program for the 600-plus-bed UC San Diego Health System in La Jolla, CA. "The fact is they have to be careful what they do."
Ferdinand Velasco, MD, vice president and chief medical information officer for Texas Health Resources, notes that while some apps "provide less return than others, they are still important, especially as you begin to experiment with innovation.
"If it is a vanilla app but gets users comfortable with the technology or concepts, but has little value to the business, it is still a major win," Velasco says.
Texas Health Resources has created internal committees to serve a checks-and-balances function regarding technological improvements, he says.
Presbyterian Healthcare Services, based in Albuquerque, NM, is using a two-way video chat program to divert nonemergent patients from the ED and to help them find a primary care physician, schedule appointments, and educate them. The program operates out of the 453-licensed-bed Presbyterian Hospital in Albuquerque.
Patient navigators there operate the video chat program for patients at two of the eight-hospital system's smaller facilities, the 198-licensed-bed Kaseman Hospital in Albuquerque and the 68-licensed-bed Rust Medical Center in Rio Rancho, NM.
Through the video chat, patient navigators help direct nonemergent cases to an appointment or follow-up care with a primary care physician, if a medical screening in the ED shows they do not need immediate care, says John D. Johnson, enterprise director of the customer service center for Presbyterian Healthcare Services.
Patient navigators meet face-to-face with patients at Presbyterian and counsel patients at Kaseman and Rust Medical Center via the video chat program when they are not handling cases in person.
Since 2010, there have been more than 8,000 patients seen by patient navigators. At least 76% of patients who went to the ED were referred to primary care physicians with "minimal complaints," Johnson says. "Our goal is to educate patients and get them established with a primary care physician, thus improving continuity of care."
As a result, the health system is predicting a savings of as much as $15 million for the three hospitals during a five-year period, according to Johnson.
The hospital system employs 10 patient navigators stationed at Presbyterian Hospital.
"We're doing the right thing for the individuals and community," he says. "Patient navigation is about connecting patients with the right provider and the right venue at the right cost."
Success key No. 1: Telehealth
Telehealth is one of the most popular technological innovations for health systems because of its capability of having a broad reach for patients, especially those who live in rural areas and at great distances from hospitals. Health systems that have been successful in developing telehealth systems are now focusing on using programs for specific service lines, such as the intensive care unit.
When the Sutter Health system launched its telehealth eICU patient safety system in the San Francisco area several years ago, it was one of the first health networks to bring online two ICU centers for constant monitoring of critically ill patients.
The eICU system has enabled Sutter to detect sepsis through a standard set of screening and treatment processes throughout its 26 hospitals, and it monitors as many as 30,000 patients from its ICU hubs in Sacramento and San Francisco, says Teresa Rincon, RN, BSN, CCRN-E, the eICU nurse director at Sutter Health.
The process also has had a carry-over effect: Sepsis-related deaths in the hospital system have decreased 29% since 2008, with more than 1,300 lives saved between 2007 and 2010. The hospital has estimated that it has saved $21 million in costs because of reduced time patients spent hospitalized during that period, according to Rincon. Length of stay has been cut at least 17%, she adds.
Screening patients for early signs of sepsis and use of sepsis bundles—a series of checklists and recommendations for providers to follow—have been implemented systemwide, especially in the EDs, ICUs, and medical-surgical units under multidisciplinary team approaches, Rincon says.
"The reality is that healthcare has evolved. In the past it has honored individual expertise and individual smartness," not working as a team, which she dubbed "colony smartness."
Nurses, too, had been used to working in silos. With the ICU "you need to work well with the emergency department and the medical-surgical units to coordinate care," Rincon says.
Under the program, intensivists and ICU-trained nurses use early warning software, advanced video, and remote monitoring to check on critical patients. Physicians monitor the system around the clock.
The system includes video camera feeds from each ICU patient room that sends patients' vital signs to eICU computer systems.
According to a review compiled by Rincon and her colleagues, ICU patients were screened for severe sepsis upon admission to one of 12 ICUs located in 10 hospitals between 2006 and 2008. In those years, nurses identified more than 5,000 patients meeting the criteria for severe sepsis. The evidence-based checklist program resulted in antibiotic administration that increased from 55% to 74% between 2006 and 2008 and central line placement (without infection) that increased from 33% to 50%.
Sharing patient data electronically, eICU nurses are now able to check with specialists who are off-site, she says.
By tracking vital signs, lab results, and orders over a period of days, eICU nurses "may pick up subtle clues and take action to stop a decline" in patients, Rincon says.
Success key No 2: Electronic medical records
As hospital systems are spurred by the government to initiate widespread EMRs in their programs, an important concern is maintaining oversight of records for specific service lines, and that's what Texas Health Resources has done with an EMR automatic risk assessment tool designed to curtail hospital-acquired blood clots.
Three years ago, the THR officials initiated a project to use EMRs to assess each patient's risk of developing a condition, and since then they have continually upgraded the program to refine efficiencies and improve outcomes, says Velasco, the CMIO.
Physicians are alerted when patients are declared at risk for venous thromboembolism and then they can establish medication procedures. Since implementation of the program, the hospital system has seen a reduction in postoperative pulmonary embolism/deep vein thrombosis by more than 20%, Velasco says.
The support program includes a protocol that detects if preventive therapy is not ordered within a timely fashion after a patient's arrival at the hospital; an alert appears in the EMR, reminding the provider to order VTE prophylaxis and suggesting use of a VTE risk assessment calculator, a support tool. With the risk assessment calculator, a clinician uses preventive therapies, such as blood thinning medications and mechanical compression devices, to promote blood flow in patients.
Through its plan, THR achieved stage 1 meaningful use requirements and received federal and state Medicaid incentive payments. Developing a leadership committee to initiate the plan was a key to its work, Velasco says.
The hospital system's chief quality officers council created a multidisciplinary VTE performance improvement committee and appointed a hospital chief quality officer as a chairman. The committee worked with staff to carry out the program."We needed hospital staff buy-in to harmonize paper-based risk assessment tools and order sets at our hospitals," Velasco says. In addition, the health system's multidisciplinary committee agreed on a set risk assessment methodology to use through varied hospital disciplines.
Among the challenges that the hospital system had to overcome was replacing paper-based risk assessment tools and order sets.
"The primary key of our success is our strong belief in the use of the electronic health record to help advance quality and patient safety," Velasco says.
Success key No 3: Robotics
Hospitals are continuing to invest millions of dollars in robotic devices for various service lines, whether it's for general, pediatric, gynecology, urology, cardiothoracic, or other minimally invasive procedures.
In essence, hospital systems are counting on robotic systems now, despite the cost and possible lack of ROI, because of what it may bring in the future: improved efficiencies and an allure for patients.
Jacques-Pierre Fontaine, MD, a thoracic surgeon at the 206-bed H. Lee Moffitt Cancer Center in Tampa, FL, says he understands that the robotic procedure in some cases may be no different in terms of clinical outcomes compared with other minimally invasive procedures.
"It's not worse for the patient; it's the same," he adds, referring to outcomes with robotic and open surgeries. "It may be more expensive for the hospital now, but we're seeing a future in it and embracing it.
"We're embracing it because the future is going to be robotic technology. It will surpass what we have now for other minimally invasive techniques. If you surf, you don't want to be behind the wave and catch up to the wave; that doesn't work. It works if you are in front of the wave and then you ride the wave."
Such an attitude is helping to drive use of the robot systems used to perform minimally invasive heart, prostate, and other surgeries.
Use of the da Vinci device, for instance, has quadrupled in the past four years, being used in thousands of hospitals for various surgical procedures. Da Vinci is a multipurpose robot that can be used for lung cancer surgery, heart bypass and valve repair operations, hysterectomies, prostate removal, and other procedures.
The popularity is increasing despite reports of uncertainty that the estimated $2 million investment may not produce better results.
However, there have been studies showing that the da Vinci devices also result in fewer complications and improved recovery.
Despite the conflicting reports, officials of some hospital systems say they are confident in the robotic device and what it means for patients as well as hospital system ROI.
The 175-staffed-bed Methodist Willowbrook Hospital in Houston, an enthusiastic supporter of robotic surgery, has shown an increased patient load as a result of the technology. It is still compiling data, but preliminary evidence shows that patients are recovering quicker and there has been greater volume, says Patricia Worley, RN, BSN, director of surgical services for the Methodist Hospital System.
It has been important for the hospital system to use the robot for a wide variety of procedures, with its largest volume in its gynecological program and then general surgery, while building volume in bariatrics, Worley says, noting that the robotic surgery system has been used in 300 cases from August 2010 to November 2011. "Our robot is used very frequently," she adds. "We are very efficient with turnovers," adding that sometimes the robot is used for three to four cases a day.
While the hospital system is still evaluating data, preliminary information supports findings of a "decreased length of stay for inpatient cases of up to two days, which could offset the charges needed to support the da Vinci use," she says.
Despite the necessary capital investment needed for the robot, the hospital "community wanted it," she says. "It was a win-win situation. Our CEO was very supportive, and we branched out into the urology program. There have been so many interested surgeons getting trained in it across specialties. The docs have been interested, and it has taken off."
The 175-staffed-bed Methodist Willowbrook Hospital in Houston, an enthusiastic supporter of robotic surgery, has shown an increased patient load as a result of the technology. It is still compiling data, but preliminary evidence shows that patients are recovering quicker and there has been greater volume, says Patricia Worley, RN, BSN, director of surgical services for the Methodist Hospital System.
It has been important for the hospital system to use the robot for a wide variety of procedures, with its largest volume in its gynecological program and then general surgery, while building volume in bariatrics, Worley says, noting that the robotic surgery system has been used in 300 cases from August 2010 to November 2011. "Our robot is used very frequently," she adds. "We are very efficient with turnovers," adding that sometimes the robot is used for three to four cases a day.
While the hospital system is still evaluating data, preliminary information supports findings of a "decreased length of stay for inpatient cases of up to two days, which could offset the charges needed to support the da Vinci use," she says.
Despite the necessary capital investment needed for the robot, the hospital "community wanted it," she says. "It was a win-win situation. Our CEO was very supportive, and we branched out into the urology program. There have been so many interested surgeons getting trained in it across specialties. The docs have been interested, and it has taken off."
Simply having a robot is a hook for patients' interest in the hospital system, Worley adds.
"We have noticed that patients are seeking use of the da Vinci when choosing physicians and hospitals that have one and/or are trained on the robot," she says. "Patients are reading bout it; they recognize the bigger cases and know that recovery times will be less … They are going to the doctors' offices and asking, ‘Do you use the robot?'"
Success key No. 4: CT scans
The Moffitt Cancer Center is using CT scans to detect lung cancer tumors after recent studies showed that they are more effective than standard x-rays.
The hospital's use of the CT scans for lung cancer screening reflects a new terrain for many healthcare systems. While some hospitals and radiology programs are using the high-tech scans in hopes of saving the lives of lung cancer patients, others are not because of continued debate over whether benefits outweigh risks. For that reason, insurance companies have been reluctant to cover the scans.
Despite the insurance issues, the Moffitt Cancer Center is using the scans, and the program has been successful in delivering more patients, says Fontaine.
Moffitt began its program after participating in a study that found screening certain heavy smokers and ex-smokers could significantly reduce their chances of dying from lung cancer. Using CT scans to screen smokers for lung cancer cuts the risk of death from the disease by about 20%, according to a National Cancer Institute study.
"Sometimes you can't wait for the government and insurance companies to make improvements," Fontaine says. "If we think as a physician and cancer institution that we can help our patients, we're going to offer it."
The NCI study, called the National Lung Screening Trial, was conducted on people at high risk of developing lung cancer to compare the differences in death rates between smokers aged 55 to 74 who had been screened annually with low-dose helical or spiral CT versus the conventional chest x-ray. The trial was developed over more than a decade and involved at least 53,000 people. Moffitt was one of 33 study sites that participated.
Lung cancer is especially deadly and difficult to diagnose and treat. More than 157,000 people annually die annually from the disease. CT scans are seen as more likely to spot small tumors compared to chest x-rays.
Armed with the study showing good outcomes from the CT scans, Moffitt Cancer Center is now offering low-dose CT lung cancer screening to patients. It is targeting people ages 55 to 74 who have had a 30-year history of one pack a day cigarette smoking. Pulmonologists at the hospital's cancer program discuss the screening with patients.
The promise of CT screening lies in the early detection of lung cancer when it is most curable, and the tool will save lives, Fontaine says.
Under the program, it is important that interdisciplinary teams evaluate the CT scans to minimize any unnecessary procedures and follow-ups such as biopsies and surgeries, he says. The results are evaluated by a lung cancer tumor board, which includes oncologists, pulmonologists, pathologists, and surgeons.
This article appears in the February 2012 issue of HealthLeaders magazine.