The state-by-state, twice-yearly rankings from Leapfrog Group provide a snapshot of safety scores at approximately 2,500 acute-care hospitals across the United States.
New findings in a national study of hospital safety suggest that hospitals are reducing avoidable deaths from errors and infections.
The Leapfrog Group's bi-annual 2018 Leapfrog Hospital Safety Grades provides letter grades for thousands of general, acute-care hospitals across the United States, and found that:
Of the approximately 2,500 hospitals graded, 30% earned an "A," 28% earned a "B," 35% a "C," 6% a "D" and 1% an "F";
Hawaii's hospitals were ranked the safest in the nation in a state-by-state comparison, with 73% of the hospitals in the Aloha State earning an "A".
Alaska, Delaware, and North Dakota were in a three-way tie for last place, with none of their hospitals earning an "A" grade.
Five "A" hospitals receiving this grade for the very first time had an "F" grade in the past;
46 hospitals achieved an "A" for the first time since the Leapfrog grading began six years ago;
89 hospitals receiving an "A" at one point had received a "D" or "F";
Continued strong performance from states including Rhode Island, Hawaii, Wisconsin, and Idaho which once ranked near the bottom of the state rankings of percentage of "A" hospitals but now rank in the top 10;
49 hospitals nationwide have achieved an "A" in every grading update since the launch of the Safety Grade in spring 2012.
Kwampirs malware was found in software for X-Rays and MRIs, and targets older, legacy systems that are prevalent in the healthcare sector and which provide relatively easy access for the virus.
Hackers known as Orangeworm are installing a backdoor malware called Trojan.Kwampirs within large corporations in the healthcare sector in the United States, Europe, and Asia, the cyber-defense firm Symantec says.
"First identified in January 2015, Orangeworm has also conducted targeted attacks against organizations in related industries as part of a larger supply-chain attack in order to reach their intended victims," Symantec says in ablog post.
"Known victims include healthcare providers, pharmaceuticals, IT solution providers for healthcare and equipment manufacturers that serve the healthcare industry, likely for the purpose of corporate espionage," Symantec says.
Kwampirs was found on software used for X-Rays and MRIs, and the malware also targets systems used to assist patients in completing consent forms for required procedures.
Orangeworm's motives with the Kwampirs malware are not clear, but Symantec says it is likely the work of an individual or a small group of hackers, and the goal is corporate espionage.
Based on the list of known victims, Symantec says Orangeworm appears to choose its targets carefully and deliberately, conducting a good amount of planning before launching an attack.
According to Symantec telemetry, almost 40% of Orangeworm’s confirmed victim companies globally are in the healthcare industry. Of those healthcare companies, the biggest number of victims are in the United States, which accounts for 17% of infections.
Once Orangeworm has infiltrated a victim’s network, they deploy Trojan.Kwampirs, a backdoor Trojan that provides the attackers with remote access to the compromised computer, Symantec says.
"Once inside, Kwampirs decrypts and extracts a copy of its main DLL payload from its resource section. Before writing the payload to disk, it inserts a randomly generated string into the middle of the decrypted payload in an attempt to evade hash-based detections," Symantec says.
If Orangeworm determines that a victim is of interest, it aggressively copies the backdoor across open network shares to infect other computers.
The malware gathers as much information about the victim’s network as possible, including any information pertaining to recently accessed computers, network adapter information, available network shares, mapped drives, and files present on the compromised computer.
Symantec says that Kwampirs uses a fairly aggressive means to propagate itself once inside a victim's network by copying itself over network shares.
"While this method is considered somewhat old, it may still be viable for environments that run older operating systems such as Windows XP," Symantec says.
"This method has likely proved effective within the healthcare industry, which may run legacy systems on older platforms designed for the medical community. Older systems like Windows XP are much more likely to be prevalent within this industry."
The deal is subject to state regulatory approval, and comes as California officials are taking a keen interest in health industry consolidation, especially in the northern regions of the state.
California's Adventist Health and St. Joseph Health have agreed to integrate clinical services under a joint operating company, the two health systems announced Monday.
The partnership will extend to clinics and facilities owned by both religious nonprofit health systems in Humboldt, Mendocino, Sonoma, Lake, Napa, and Solano counties, subject to regulatory review.
Adventist Health and St. Joseph Health will retain existing hospital names, licenses, capital assets and employees. The two systems hope to have the deal finalized by the end of the year. Financial terms were not disclosed.
“Adventist Health and St. Joseph Health believe this is the right thing to do for the communities we serve,” Jeff Eller, Adventist Health president of the Northern California region, said in a media release.
“Patients will benefit from more access points, better health outcomes and controlled costs by coordinating their care across the spectrum of their health needs,” Eller said.
The affiliation applies to Adventist Health Howard Memorial, Adventist Health Ukiah Valley, Adventist Health Clear Lake, Adventist Health St. Helena and Adventist Health Vallejo and Home Health; and to St. Joseph Hospital Eureka, Redwood Memorial Hospital, Santa Rosa Memorial Hospital, Queen of the Valley Hospital and the St. Joseph Home Care Network.
The arrangement does not include the other 15 Adventist Health hospitals in the western United States or the other 50 Providence St. Joseph Health hospitals located throughout the western United States and Texas.
Last month, the California Attorney General’s Office filed suit against Sutter Health, alleging that the largest health system in Northern California is engaged in anticompetitive practices that are raising healthcare costs for consumers.
"Sutter Health is throwing its weight around in the healthcare market, engaging in illegal, anticompetitive pricing that hurts California families," California Attorney General Xavier Becerra said of the filing.
The AG’s complaint came shortly after a new report by University of California Berkeley’s Petris Center on Health Care Markets and Consumer Welfare that documents how the rapid consolidation of healthcare markets in California has led to rising healthcare costs for consumers throughout the state.
Sutter Health has called the attorney general's filing "factually inaccurate."
"It mischaracterizes the activities of our not-for-profit organization, and it fails to adequately account for Northern California’s robust and competitive health care environment," the health system said in prepared remarks.
The health insurance lobby says the duration of short-term plans should be extended no longer than six months, and that consumers should be clearly told the limits of their coverage.
The federal government's proposal to relax coverage requirements for 90-day, short-term health plans is getting a chilly reception from the health insurance industry.
America's Health Insurance Plans incoming President and CEO Matt Eyles told the Department of Health and Human Services that the short-term plans should not be offered as a full replacement for comprehensive coverage.
"We are concerned that substantially expanding access to short-term, limited duration insurance will negatively impact conditions in the individual health insurance market, exacerbating problems with access to affordable comprehensive coverage for all individual market consumers," Eyles saidin a letter to HHS Secretary Alex Azar.
Under the proposed rule, short-term insurance would not have to comply with coverage mandates under the Affordable Care Act, which include preexisting condition protections, preventive care, prescription drugs and mental health coverage. The proposed rule also eliminates the three-month limit on the duration of the plans.
Critics contendthat the restrictions on short-term plans were put in place to prevent health insurance companies from siphoning off healthy people at the expense of the more comprehensive, and expensive ACA-mandated options.
Eyles appeared to agree with many of the criticisms.
In his letter to Azar, Eyles said that the short-term plans should be extended no more than six months, and should provide consumers with clear disclosures about the extent of the coverage and the availability of more comprehensive coverage through the healthcare marketplace.
He also recommended that the rule change not go into effect before Jan. 1, 2020.
Earlier this month, the Alliance of Community Health Plans also raised concerns about the proposed rule in a letter to Centers for Medicare & Medicaid Administrator Seema Verma.
"With few advantages of short-term, limited duration insurance and the high risk of introducing additional instability in the small group and individual marketplaces, ACHP recommends that the Departments not finalize the proposed rule," ACHP President and CEO Ceci Connolly said in the letter.
"We suggest that other policy approaches, such as establishing a federal reinsurance program for the ACA-compliant individual and small group markets, would be far more effective in promoting affordable coverage options," Connolly said.
Patient factors associated with a lower use of opioids include older age, no history of anxiety, and lower pain scores at discharge. Researchers say one-size-fits-all opioid prescribing may not be in patients' best interest.
Nearly one-third of patients at three academic medical centers used none of the opioids they were prescribed after surgery, according to a survey byMayo Clinic.
Researchers surveyed 1,907 patients who underwent 25 common surgeries at three academic medical centers and found that:
At discharge, 92% of patients received an opioid prescription.
Of the opioids prescribed, 63% went unused.
90% of patients were satisfied with their pain control.
28% said they were prescribed too many opioids; 8% said they were prescribed too few.
The median amount of opioids consumed per patient equaled about six pills of 5-milligram oxycodone.
The number of opioids patients needed after discharge also varied significantly depending on the type of surgery.
"This research provides a road map for physicians and surgical departments. It shows there are certain surgeries and types of patients who are likely receiving significantly more opioids than needed," says study senior author Elizabeth Habermann.
Patient factors associated with a lower use of opioids include older age, no history of anxiety, and a lower pain score at discharge. Conversely, factors that could potentially predict the need for more opioids include those younger in age, a history of anxiety and a higher pain score at discharge.
"Opioid prescribing guidelines should be based on evidence, considering patient factors and the type of procedure, but also allowing for prescriber discretion," Habermann says.
"This research and numerous other opioid prescribing projects at Mayo Clinic are about identifying the best approach for each individual patient, whether that’s increasing, decreasing or maintaining prescription levels."
Habermann says one-size-fits-all maximums for opioid prescribing that are being advocated by many prescription drug plans and legislators to treat acute pain may not be in patients' best interest.
Carbon dioxide emissions generated by the healthcare system could play a role in approximately 20,000 premature deaths each year that are linked to air pollution.
The nation's $3.3 trillion healthcare system spews about 10% of the carbon dioxide generated in the United States each year, anew study from The Commonwealth Fund.
The U.S. healthcare system emitted 655 million metric tons of carbon dioxide in 2011, which accounted for around 10% of the CO2 generated in the United States that year.
By reducing carbon emissions and building infrastructure more resilient to natural disasters, The Commonwealth Fund says healthcare organizations can reduce their carbon footprint and improve health. Some providers are already taking action.
For example:
Kaiser Permanente has reduced greenhouse gas emissions by 29% while increasing membership by 20%. Kaiser projected its annual greenhouse gas emissions would decrease from 806,000 metric tons to 617,000 metric tons by 2017 as a result of clean-energy practices.
After a devastating storm in 2001 halted almost all operations at the Texas Medical Center, the organization rebuilt with a “hazard mitigation plan.” The center built its own new heat and power utility plant at an elevation to avoid flooding. The plant emits less carbon, and is managed by an independent power company, eliminating dependence on the Houston utility grid. When Hurricane Harvey hit, the medical center remained almost fully operational.
New York City’s Bellevue Hospital, which serves more than 500,000 patients annually, was forced to close temporarily and move patients when Hurricane Sandy struck in 2012. When it rebuilt, many of the replacements for flooded electrical and mechanical systems were positioned on higher floors, and the hospital’s emergency power system added a generator to reduce dependence on the city’s grid.
Partners HealthCare is developing a climate adaptation plan in partnership with the city of Boston. Partners recognized the vulnerability to climate change of its Spaulding Rehabilitation Hospital on Boston’s waterfront, and adopted a set of best practices to make the building more resilient to rising sea levels.
The Commonwealth Fund says health systems are beginning to see the value in reducing carbon emissions, and not just for the environment.
"This might not only reduce the cost of care — one of the biggest woes ailing the U.S. health system — but also help fulfill the obligations that come with the industry’s size, its huge carbon footprint, and its mission to improve health," the report said.
"Effective strategies for addressing climate change should become an essential attribute of high-performing health systems in the future."
Advocates urge clinicians to consult with elective surgery patients about local anesthetics shortages, the potential health risks, and alternative forms of pain management.
A global shortage of local anesthetics threatens patient care and could worsen the opioid crisis as patients and their caregivers use other methods of pain relief, the American Society of Regional Anesthesia and Pain Medicine says.
Because of that, ASRA is urging hospitals, physicians and other clinicians who provide elective surgery to consult with their patients ahead of the procedure to warn of potential local anesthesia shortages and their potential health risks, and to discuss alternative strategies for pain management.
"This conversation needs to be taken to the public," says Edward R. Mariano, MD, a professor of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine.
"If I were helping a family member make a decision about when and how to have a knee replacement surgery scheduled, I would want to know whether the hospital where my mom or dad was having knee replacement actually has suitable stock of local anesthetics so my family member is going to get good care," Mariano says.
Even minor surgical procedures can lead to long-term opioid use. Regional anesthesia, especially with continuous peripheral nerve block techniques, has been shown repeatedly to reduce patients’ need for opioid analgesia, Mariano says.
Now, this care is threatened with ongoing global shortage of local anesthetic drugs, including bupivacaine, lidocaine, ropivacaine. Targeted injections of these numbing drugs at the surgery site can eliminate the need for injectable opioids such as fentanyl, hydromorphone, morphine, which also are in short supply.
Mariano says elective surgery patients oten know the date of their procedure months in advance, which provides an excellent window of opportunity for clinicians to consult with them about pain management.
"From the patient point of view, when you show up for your surgery you don't necessarily know when you go in whether that hospital is suffering from a local anesthetic shortage," he says. "It is not a reason that most hospitals would consider for delaying or even cancelling elective procedures. But, we know from our data that certain types of anesthetics and pain control modalities have a direct positive effect on decreasing opioid use."
Mariano says patients must be fully informed about any potential health risks before elective surgery.
"For knee replacement patients, for example, there is an association between having a spinal or an epidural anesthetic and having a lower risk of 30-day mortality. That's huge," he says.
"We know this effect is greater if you happen to be a patient with obstructive sleep apnea. There was a recent article that brought up general anesthesia and memory loss," he says. "So, if you have a reason to avoid general anesthesia and you have a surgery that doesn't require general anesthesia, then as a patient you have a right to request a spinal anesthetic, and you have the right to schedule when you know that that is going to be the anesthetic available to you."
ASRA will take up the issue during a session on April 21, held in conjunction with the 2018 World Congress on Regional Anesthesia and Pain Medicine. Mariano is asking clinicians and healthcare administrators who are dealing with local anesthetics shortages to help find solutions.
"I'd be interested if they have found alternative vendors or, if they've come up with strategies to avoid effects on clinical care, I'd like to hear about it," he said. "If their hospital has started introducing these drug shortage conversations in their process of surgical informed consent I'm interested in hearing about that."
(Providers interested in sharing their solutions can reach Dr. Mariano at emariano@stanford.edu)
Healthcare mergers and acquisitions saw a banner year in 2017, despite economic and political uncertainty. Analysts believe that lower corporate taxes will continue to lure foreign investors into the $3.3 trillion U.S. healthcare sector.
Healthcare merger and acquisition values surged globally in 2017, rising 27% to $332 billion while the deal count increased 16%. That robust activity should continue in 2018, according to a report from Bain & Company.
"The industry is at a major inflection point, and as a result, we're seeing category leaders consolidate and the silos between sectors starting to blur," said Dale Stafford, partner and leader of Bain’s Americas M&A practice.
"While total corporate deal value in healthcare hasn't quite equaled its 2015 peak, average annual activity over the past four years has been strong, nearly twice the level of the previous four years. This activity is profoundly reshaping the industry," Stafford said.
The investment in the healthcare sector in the United States and globally continued in 2017 despite unease about the state of the global economy, and political turbulence in the U.S. around efforts to roll back the Affordable Care Act.
Still, Bain said investors are lured into the $3.3 trillion U.S. healthcare sector by fundamental drivers that include an aging population, a rising prevalence of chronic disease, the robust development of new drugs and medical devices, and the fragmented and inefficient care delivery system that is ripe for disruption.
Looking Ahead in 2018
Bain says it expects the continued high level of healthcare M&As to continue in 2018, despite valuations at or near record high levels.
"Already, we've seen aggressive moves by corporates across healthcare, retail and technology this year, fusing sectors and leading others to make offensive and defensive moves," Bain says.
Forces that will affect the M&A market this year include:
Evolving laws and regulations. U.S. tax reform will mean lower corporate rates, potentially making healthcare assets attractive to foreign investors eager to expand in the world's largest economy.
Innovation. In the pharma sector, the development of next-generation platforms such as biosimilars and gene therapy will accelerate. They have the potential to disrupt the industry, creating buying opportunities while putting stress on traditional companies.
Changing nature of total shareholder return. Rising stock markets have been very generous to the shareholders of public healthcare companies, but that’s not something they can count on going forward. Forty-five percent of TSR growth at publicly traded global healthcare companies over the past five years came from an expansion of price-to-earnings multiples—that is more than growth from either revenue or earnings.
Bain says companies will face renewed pressure to build total shareholder return through revenue growth, margin expansion or financial leverage.
"If they cannot drive revenue growth internally, they’ll likely look for it in acquisitions, adding further fuel to healthcare M&A," Bain says.
The vaguely outlined collaborative between Amazon, Berkshire Hathaway, and J.P. Chase Morgan poses no short-term threats to established health insurance companies, Moody's says.
"Both of these mergers are designed to better control rising medical costs, which is one of the most vexing problems facing health insurers," Moody's says this week in its Healthcare Quarterly.
Prescription drug prices are a big driver of rising medical costs, and the Health Care Cost Institute reports that prescription drugs increased from 17% to 19% of the total healthcare spend between 2012 and 2016.
"The annual medical cost trend for insurers, which consists of the level of utilization, medical inflation, the impact of technology advances and the sources of medical care (i.e. low-cost clinics versus high-cost hospitals), has been moderating in recent years. But it still came in at approximately 6% in 2017, well above inflation," Moody's says.
According to Moody's:
The CVS/Aetna merger has the potential to lower medical costs as Aetna will be better able to engage with its members as they purchase drugs at CVS retail pharmacies or through its prescription drug programs. The combination will foster increased use of lower-cost care as Aetna members access routine care at CVS stores and Minute Clinics.
Cigna will incrementally benefit from its purchase of Express Scripts by combining its own integrated solutions with Express Scripts' ability to manage pharmacy costs. While Express Scripts does not have a retail presence, Cigna will benefit from a more diversified revenue stream.
The impact of these mergers on the health insurance sector is limited. When finalized, the three largest PBMs will each be part of a vertically integrated entity that includes a large health insurer. That trend started in 2015 when UnitedHealth Group bought Catamaran, now known as OptumRx.
As a result of these deals, most other health insurers will have to contract with a PBM that is owned by a competing health insurer. Competition among the PBMs for market share will remain intense. Their offerings to third parties will have to be competitive with their internal offerings or they'll risk losing customers. Because of that these vertically integrated offerings could benefit the broader industry over time.
The mergers are a credit negative for branded drug makers. For example, Aetna could encourage policyholders to buy generics at CVS pharmacies or through its prescription drug programs. The mergers will have little impact on generic drug makers, since both CVS and Express Scripts are already part of large generic drug purchasing alliances.
Amazon, Berkshire Hathaway, J.P. Morgan Chase
In a separate analysis, Moody's says the announcement in January that Amazon, Berkshire Hathaway Inc., and J.P Morgan Chase would combine to form some sort of health insurance venture likely would have little short-term credit impact on the commercial healthcare sector.
"The new venture is likely to have little, if any, credit impact on the health insurance sector over the next three years," Moody's says. "The three companies combined have less than one million employees, which is a fraction of the membership of the large, publicly traded health insurers."
The three companies provided scant details on what their combined initiative would involve, but Moody's says it likely would be designed to leverage the companies' bargaining powers with payers and providers.
"Whether or not the announcement is a harbinger of more heated competition from non-traditional participants in health insurance, outside of these three companies, remains the larger question," Moody's says.
"Our view is that the industry leaders are not sitting still and are taking steps to enhance capabilities. While improvements by new competitors are always possible, we do not see any immediate threat to the large incumbents."
Federal prosecutors allege that Allergan knowingly sold LAP-BANDs with defective or flawed access ports and lied to the FDA about the cause of the leaks.
Drug and medical device maker Allergan Inc. will pay $3.5 million to resolve whistleblower allegations that it knowingly sold defective LAP-BAND surgical gastric bands to healthcare providers, the Department of Justice said.
"Patients have every right to expect that medical devices used during surgery are free of defects," Robert K. Hur, U.S. Attorney for Maryland, said in a media release.
"Patients also have the right to expect that procedures involving medical devices have been subject to the rigorous review and approval process of the Food and Drug Administration," Hur said. "When marketing and selling medical devices that may have defects or may be used in unapproved procedures, patients can be put at risk."
An Allergan spokesperson on Wednesday declined to comment on the settlement.
The LAP-BAND is an inflatable silicone band that is placed around a patient’s stomach during surgery. Adding or removing saline through a subcutaneous access port adjusts the LAP-BAND, which constricts or expands the size of the stomach pouch.
Federal prosecutors allege that between 2008 and 2010 Allergan knowingly sold LAP-BANDs with defective access ports. To conceal the defect and to induce healthcare professionals to continue using the LAP-BAND, Allergan misrepresented facts concerning the cause of access port leaks to the public and the FDA.
Allergan allegedly failed to collect data and complaint files, nor did it provide remuneration to clinicians who reported access port leaks, DOJ said.
In addition, prosecutors allege that between 2008 and 2012, Allergan knowingly advertised, marketed, and distributed LAP-BAND for use in two procedures that were not approved by the FDA.
Allergan allegedly induced clinicians to use LAP-BAND for these unapproved procedures through proctoring, workshops, advisory boards, and training events in which these two uses were discussed and/or demonstrated.
The two whistleblowers who brought the suit will split $594,064, the federal government will collect $3.3 million, and state Medicaid programs will receive $200,000.
The settlement was filed with the U.S. District Court in Maryland.
