A report finding no connection between socio-economic status and readmissions rates is being faulted for its lack of granularity by advocates for safety net hospitals.
The ongoing debate about the role of socio-economic status in hospital readmissions was rekindled this month with a report in Health Affairs showing no connection between the two.
"Our paper should not be interpreted to suggest that socioeconomic disparities in health do not exist," Susannah M. Bernheim, MD, MHS, director, Quality Measurement Programs at the Yale-New Haven Hospital Center for Outcomes Research and Evaluation (CORE), said in an email exchange with HealthLeaders Media.
"Socioeconomic status is an important determinant of health status," she says. "What we have shown is that for quality measures, like the readmission measures that already account for differences in patient illness, socioeconomic indicators do not have a big additional effect on hospital results."
America's Essential Hospitals, an association representing safety net hospitals, took issue with the findings and said it relies upon ZIP code-level data that doesn't provide enough granularity about specific neighborhoods and streets where some safety net patients reside, or what goes on inside those homes.
"We believe the authors of the article have not truly identified the data that can help tease out the variables in geographic areas to fully understand why some neighborhoods are more likely to see readmissions than others," says Beth Feldpush, senior vice president of policy and advocacy at America's Essential Hospitals.
'Vested Interest' in Existing Measures
"They did take a look at demographic variables. The problem is they looked at ZIP codes where patients reside as well as dual eligibility for Medicare and Medicaid. We believe that ZIP code does not get you down to a finely divided enough area to understand the impacts."
Feldpush also noted that the Yale researchers are also "the developers of the readmissions measures themselves. So, you can understand they already have a vested interest in the measures as they are constructed."
Bernheim says CORE research uses U.S. Census data.
"The neighborhood data that we used comes from what is called the American Community Survey, which is collected by the U.S. Census Bureau… which includes information about things such as poverty, income and education levels, or housing within a neighborhood," she says.
She defended the study findings as "quite robust."
"Since we completed this paper, we have continued to study this topic and we consistently get the same results. Adjusting the readmission measures for patient socioeconomic status does not make a difference to hospitals' results even when we use other indicators of patients' socioeconomic status," Bernheim says.
"For instance, we recently presented results showing that adjustment for socioeconomic status measured at the census block group-level also does not affect hospitals' readmission results. That research used an indicator linked to a much smaller neighborhood area than the ZIP code areas used for this paper, but it didn't change the findings. Some people think that results would change if we just had the perfect way to assess socioeconomic status, but that doesn't seem to be true."
Bernheim concedes that people may find it "surprising" that hospitals caring for poorer patients generally perform well on Medicare readmissions measures, and she offered "few things (that) may help explain this finding."
"Most importantly, the readmission measures that Medicare reports are adjusted for patients' level of illness. So if poorer patients are sicker when they arrive at the hospital, the readmission measures already account for those differences among the patients," she says.
"Our study used the measures that are reported by Medicare nationally, which take into account differences in how sick patients are," she says.
"We asked whether socioeconomic status played a major role in hospital readmission rates above and beyond the differences in illness that the measures already take into account, and we found it did not."
Only 20% all hospitals scored a Four-Star rating from the Centers for Medicare & Medicaid Services. One rural hospital CEO talks about getting the message out to patients and their families about the high quality care delivered locally.
Susan Starling, CEO of Mercy Health's Marcum and Wallace Memorial Hospital in Irvine, KY says she's reasonably happy with the Four-Star rating her 25-bed critical access hospital received from the Centers for Medicare & Medicaid Services. That is, until she has to explain to patients why the hospital didn't merit Five Stars.
"I don't think the patients or their families understand the whole rating system," Starling says. "We may perceive Four Stars as really great because there aren't many Five Stars in the U.S., but I don't know that patients understand. They want to know why we're not Five Stars."
Although much of the rankings are based upon patients' perception of their care, Starling says "it's a complicated rating system that is not really set for patients to be able to have a good understanding of what the ratings mean."
"In our market area we do well compared to our competition, but I am not sure how you can market that," she says. "There is opportunity to do that, but I don't know what it is."
Like many hospital leaders, Starling says Marcum and Wallace scores well with the factors it can control.
"Our hospital has high scores in cleanliness. We focus on making it a good patient experience. In a rural hospital we are family and friends caring for family and friends," she says.
Bigger is Not Always Better
"It is a positive environment for our patients where they have good outcomes. They feel comfortable being here. That misnomer of 'bigger is better' is not always true. Our culture is to provide good care to our patients, which is reflected in our rating."
The demerits come, she says, when Marcum and Wallace is hit for factors over which it has little control: For example, payer-mandated discharges that are perceived as premature by patients, and post-discharge care services in a rural region with scarce resources.
"More and more we are trying to get the patients back out into the community, but in rural settings there are often limited options for after-hospital care," Starling says. "We do the best we can, but really patients sometimes aren't ready to go home, even if Medicare or their insurance carriers are demanding that they get back out into the community."
"We don't have a lot of access to home health services and those things such as Meals on Wheels and we have limited physical therapy services out into the community. Those are the challenges that we face in rural that makes it harder to get a better score on post-hospital settings."
To compensate for a lack of resources, Starling says Marcum and Wallace does "everything we can to make it a successful discharge. We work really hard on trying to make sure they have everything they need, the education, the medications, the tools. But again, if that patient goes home and they don't physically feel that they are ready, maybe they don't have the support system at home, then we don't get a good rating, even though we don't have a lot of control over that part of it."
The hospital's attempts to provide resources for a post-discharge care network are hampered by a lack of money.
"Home health pulled out of rural communities because it is not financially feasible for them to be here. Investing in those services is not a good financial move on my part," Starling says.
"The government is not looking at the needs of rural America, and the reimbursement for home health in rural, so the services are just pulling out. The durable medical equipment companies are pulling out of rural as they face these financial challenges. We are the first to get cut."
With the goal of someday achieving a Five-Star rating, Starling says Marcum and Wallace is borrowing strategies from accountable care organizations and forging ahead with new initiatives.
"We are working closely now with a care coordinator in our physician clinics and making sure she understands what is happening with the patients when they are in the hospital, so that when the patient is discharged the coordinator is aware of it," she says.
"We are looking at the patients' different needs and services that they'll need and trying to coordinate that. We just received a federal grant that is going to help us work on medication therapy for the patient and have a pharmacist in some of the clinics help these patients have a better understanding of their medications and monitor them and what the patient understands, what exactly is this medication for."
Using ACO strategies makes sense even if you're not in an ACO, Starling says, because the star ratings are part of larger movement to measure the efficacy of patient-centered and value-based care that hospitals provide.
"Now we are cost based, but that going to change for critical access hospitals," she says. "My goal as the CEO is to try to improve the health of our patients, do the things that we think can help our patients with respect to population health. I am laying the foundation to be prepared for the future, whatever the future is."
"We take our work seriously. We always strive to be a high-performing institution and we measure ourselves against the best healthcare delivery systems we can find, focused on patient and staff satisfaction," says Putnam.
According to CMS, only 102 (2.2%) of the nearly 5,000 rated hospitals earned five stars, and only 934 hospitals, about 20.3% earned four stars, including Margaret Mary Health.
"We've been in the National Rural ACO, which has focused on a lot of quality measures and helped us figure out where we needed to be," Putnam says.
"We are constantly comparing ourselves with others in what we can do better and searching for best practices. That's been pretty active for the last three years, so we didn't anticipate being surprised by the star ratings."
Putnam says that Margaret Mary's membership in the National Rural ACO and in the Suburban Health Organization, a group of eight hospitals in the Indianapolis area, has provided a framework for improvement.
"When you look at all the hard data you have on how you are delivering care, it makes you look at all the data a lot more closely," he says.
"You find out who is doing well and you have a way to find out how to improve your processes because you know they do well and they want to see you do well. This small network of hospitals has shared a lot. A lot of this is an informal process of working together to improve."
In one telling example, Putnam recalls that Margaret Mary clinicians and administrators were baffled by their relatively high pneumonia mortality statistics.
"We were scratching our heads trying to figure out why," he says. "We work with a great infectious diseases physician. We have a lot of histoplasmosis in the area and a lot of COPD, but why is our pneumonia mortality so high?"
"As we got down to it, our processes were good, but our charting of severity of illness was not," he says.
"When we looked at it, our case mix index, our severity of inpatients for all of our Medicare patients, was 1.0. When we had it assessed, we found out that our real severity of illness should have been 1.4 or should have reflected the real disease process going on."
Medicare Pays on Cost of Illness, Not Severity
The problem, it turns out, was that Margaret Mary didn't compare well with general acute care hospitals, because critical access hospitals aren't paid on severity of illness. They're paid on cost.
"By and large we don't document that well," Putnam says. "We're paid on our costs, so how severe the illness is on the Medicare report doesn't get charted. When we looked at the (prospective payment system) hospitals, they are paid on severity of illness, so they track that very carefully and report that very carefully."
"When we figured out what other hospitals were doing and how to do it correctly, all of a sudden our pneumonia scores are accurately reflecting what is going on."
Even though Margaret Mary got a relatively high score, Putnam says he is not satisfied with the rating, neither for his hospital, nor for all hospitals with a mission to improve community health and serve anyone.
Many of CMS's 5-Star hospitals, he says, are niche and specialty hospitals that don't have an open emergency room. "So, they don't take all of the community. They don't take everyone coming through the door," he says.
'Slanted' Metrics
"I don't know all the metrics that go into the rating system, but it is definitely slanted. If you can pick and choose your patients, you do better on the ratings. From the community hospital's perspective, where you are serving and benefitting the whole community, they don't fare as well, yet I know they do an excellent job, especially given their patient population."
It's frustrating, he says, because "ratings only tell a small portion of a story of any hospital. When I look at the ratings, I see some hospitals that are very solid institutions that provide great care and are not ranked very highly. I don't like to see anything that discourages the patients' confidence in their local community hospitals."
As hospitals cash in on the lucrative fees that come with trauma center status, unregulated growth is diluting patient volumes and doing more harm than good, research shows.
The lightly regulated and poorly coordinated designation for trauma care centers in some states has created an oversaturated system in some regions that dilutes patient volumes and leads to worse outcomes, according to a study in the Annals of Surgery.
"It takes about three years for the impact of increased patient volume to translate into improved patient outcomes," said lead author Joshua Brown, MD, a research fellow in the Division of Trauma and General Surgery in the University of Pittsburgh Medical Center School of Medicine.
"Siphoning of patients through unregulated growth of unnecessary trauma centers can have a profound detrimental impact on patients that isn't immediately obvious. Before designating a new trauma center, serious consideration should be given to how that designation will affect patient volumes over time at trauma centers throughout the region," Brown said.
Brown and his colleagues at UPMC examined records of nearly 840,000 seriously injured patients seen at 287 trauma centers between 2000 and 2012.
The centers averaged 247 severely injured patients per year, and 90% of the cases involved blunt injury. The researchers compared the expected death rate for each center to the center's actual death rate, if everything involving each trauma patient's care had gone perfectly.
Each 1% increase in patient volume at a trauma center was associated with 73% better odds of a patient surviving. Conversely, each 1% decrease in volume was linked to a two-fold worsening in the odds of a patient surviving.
With too many trauma centers, Brown said, "you run the risk of diluting the volume. We saw on balance that when a trauma center increased volumes, you saw an improvement in outcomes. When centers decreased their volume, the worsening of their outcomes was actually worse than the benefit gained from another center increasing their volume. So, diluting that could potentially produce a net negative benefit in the overall system."
Brown says there has been a significant increase in the numbers of hospitals that have sought trauma center status, particularly in Texas and Florida.
"The pendulum has swung. In the 1990s and the early 2000s being a trauma center was a money-losing prospect. So, the healthcare system has created some incentives to ensure access to trauma center care," he said.
Financial Incentives and Trauma Centers
"Now a lot of states will pay fairly large trauma team activation fees. It has created an incentive where trauma centers can make money by collecting these fees. So a number of these smaller Level 2 and 3 trauma centers have been popping up in some areas in the South and that has become a problem for the larger academic trauma centers in those areas."
Brown says it's time to re-evaluate and better coordinate how trauma center designations are awarded with an eye on the effect for the entire care delivery system in a particular region.
"The way it has been done is a hospital says 'we want to be a trauma center' and there are a number of boxes they need to check. If the county goes along with this most of the time the state or the accrediting agency will say 'you can be a trauma center,'" Brown said.
"We should shift that perspective to saying 'what is the overall impact on the trauma system that you are going to be part of? Is there a population center that will support a new trauma center, or are you going to be pulling volume from other trauma centers that could develop into a net negative impact on the overall trauma system?'" Brown said. "Taking the perspective on how the whole trauma system is impacted is the way to go."
While designating trauma center status should be a better regulated process, Brown says it's a job that should remain primarily in the hands of state and local governments.
"It needs to be done on a fairly local level," he said, "but support in terms of funding and legislation at the federal level can push some of these accreditation agencies in that direction to take this kind of perspective for the way they develop their trauma systems."
Hospital groups pan the 'deeply flawed' Hospital Compare ratings, which critics say unfairly penalize safety net hospitals and mislead consumers.
The Centers for Medicare & Medicaid Services on Wednesday unveiled its updated Overall Hospital Quality Star Ratings despite appeals for delay from the hospital industry.
"When individuals and their families need to make important decisions about healthcare, they seek a reliable way to understand the best choice for themselves or their loved ones," CMS Center for Clinical Standards and Quality Director Kate Goodrich, MD, said in a blog post accompanying the data release.
"Today, we are updating the star ratings on the Hospital Compare website to help millions of patients and their families learn about the quality of hospitals, compare facilities in their area side-by-side, and ask important questions about care quality when visiting a hospital or other healthcare provider."
Goodrich said the new Overall Hospital Quality Star Rating methodology takes 64 existing quality measures already reported on the Hospital Compare website and summarizes them into a unified rating of one to five stars.
"The rating includes quality measures for routine care that the average individual receives, such as care received when being treated for heart attacks and pneumonia, to quality measures that focus on hospital-acquired infections, such as catheter-associated urinary tract infections," she said.
CMS said the Star Rating is based on questions such as:
How often do patients get an infection after surgery?
How long on average do patients have to wait in the Emergency Department before seeing a provider?
How often do patients develop complications after hip replacement surgery?
How likely are patients to get readmitted to the hospital after a heart attack?
Will patients receive multiple CT scans or MRI's?
Of the nearly 4,599 hospitals that were graded:
102 (2.2%) received 5 stars;
934 (20.3%) received 4 stars;
1,770 (38.5%) received 3 stars;
723 (15.7%) received 2 stars;
133 (2.9%) received 1 star; and
937 (20.4%) received no ranking due to insufficient data.
The average Star Rating for teaching hospitals (mean = 2.87) was similar to, but slightly lower than that for non-teaching hospitals (mean = 3.11).
Hospital Groups 'Disappointed'
Hospital groups had called on CMS to delay the release of the new ratings until it could address hospitals' concerns raised about the accuracy and correct use of the data. When CMS released the updated ratings on Wednesday morning, the critics pounced.
Rick Pollack, president and CEO of the American Hospital Association, called the ratings "confusing for patients and families" and "not ready for prime time."
"Healthcare consumers making critical decisions about their care cannot be expected to rely on a rating system that raises far more questions than answers. And it adds yet another to a long list of conflicting rating and ranking systems," Pollack said.
"We are especially troubled that the current ratings scheme unfairly penalizes teaching hospitals and those serving higher numbers of the poor."
Pollack called on CMS to work with the hospital lobby and Congress to improve the ratings,
Association of American Medical Colleges President and CEODarrell G. Kirch, MD, said the ratings give patients an incomplete picture of hospital performance.
"They are based on a deeply flawed methodology that does not take into account important differences in the patient populations and the complexity of conditions that teaching hospitals treat," Kirch said.
"As a result, many of the nation's leading teaching hospitals—institutions that provide the most advanced healthcare in the world—have been assigned lower ratings than other hospitals that treat patients with less complex conditions or that treat only certain conditions."
Kirch said that CMS's claims that the ratings measure hospitals on an equal basis is "unfortunately not true."
"Teaching hospitals perform a wide array of complicated and common procedures, pioneer new treatments, and care for broader socio-demographic patient populations that may not have access to regular care," he said. "Yet under the new ratings, they are compared directly to hospitals with more homogenous patient populations and hospitals that do not do enough procedures to be counted."
As a result, Kirch said, CMS used more than 60 measures to calculate ratings for teaching hospitals and as few as nine measures on some hospitals that treat patients with less complex conditions or that treat a limited number of conditions.
"AAMC analysis of the ratings has confirmed that the lower the number of measures a hospital reported, the more likely a hospital was to receive a higher star rating," Kirch said. "In fact, hospitals that reported on only 60% of the metrics or less received almost half of the five-star ratings."
Bruce Siegel, MD, president and CEO of America's Essential Hospitals, echoed those complaints.
"The star ratings exist partially in a black box, incorporate measures that miss clinically relevant data, and fail to adjust for patient circumstances that influence health and health care outcomes – circumstances outside a hospital's control," Siegel said. "Consumers deserve accurate, comprehensive, and relevant information to make health care decisions. Hospitals deserve to be evaluated on a level playing field. The star ratings accomplish neither."
CMS moved quickly to release the ratings after announcing on Monday that they would be released "shortly."
A disinterested antitrust litigator discusses the legal merits of the suits brought by the Department of Justice against Aetna and Anthem.
The U.S. Department of Justice filed suit this month to block two proposed mega-mergers of health insurance giants Aetna with Humana and Anthem with Cigna, claiming the consolidations would stifle competition and innovation and lead to higher costs for healthcare consumers and providers.
In an interview with HealthLeaders Media, antitrust litigator Jay L. Levine with the Washington, DC office of Porter Wright Morris & Arthur, LLP offers his disinterested analysis on the Department of Justice's lawsuits to block the two mergers. The following is an edited transcript.
HLM: What does the government have to prove to win this case?
Levine: The government has to prove the relevant product market, the relevant geographic market, and they have to prove that within those markets competition is going to be substantially lessened as a result of these mergers.
That means that prices are going to go up, innovation and quality is going to go down, and that there aren't any counterbalancing procompetitive benefits.
Nobody in the market or coming into the market would have a competitive response that will compete away these anticompetitive effects, these additional price hikes, and/or reductions in innovation and quality.
On the flip side, almost always the primary focus of defendants in a merger case is to show that the government definition of a market is off.
Therefore, the presumption that the government makes that the merger is unlawful is incorrect because the market shares are invalid, that the real market shares are far less, and that competition will thrive post transaction.
They also want to show that other companies, even if they are not in the market, are poised to enter the market should they see an opportunity if the merging companies raise prices or reduce quality.
HLM: The DOJ suits resonate on a common sense level, in that combining four of the nation's five biggest health insurance companies does not seem to be good for consumers. Will that perception factor into these suits?
Levine: There is a sort of PR aspect to 'Oh my god! Household names are merging!'. Even in the political climate we are in now people are railing against 'big is bad' and 'we aren't doing enough to stop these mega mergers.'
Obviously, a judge looking at this case may be influenced by that, but the framework of the law is not 'big is bad.' You can have No. 1 and No. 2 in an industry merge if there is enough competition around.
The question is not always a visceral reaction to big is bad, but let's get to the details and where exactly will this merger harm competition? The judge still has to dig in and figure that out.
Plus, each merger analysis has to stand on its own. I don't think one can do a lobotomy and not be aware that there is another merger going on that obviously has some implications.
But the judge is going to have to write an opinion that is fact-specific to that merger. He is going to have to find on the facts that stand trial that the government has made out a case that there will be in some relevant market consumers that will be harmed.
HLM: How do these two separate suits differ?
Levine: In the Anthem/Cigna case, DOJ is taking on far bigger markets. If you want to think about it, there are three seller markets and one buyer market. Whereas in the Aetna/Humana case it';s limited to certain counties and two specific products.
In that respect, what they've taken on is a little bit less grandiose. The two product markets alleged there, the exchanges in certain counties and the Medicare Advantage products in certain counties were viewed as them selling the plans.
Every case is fact-specific in to what markets are we talking about. These two complaints are not identical because they have different geographies and they also have different product markets that they are worried about. In that respect, the facts and issues that are going to be litigated are going to be very different.
HLM: In which suit do you believe the government has a stronger argument?
Levine: A lot of people have posited that the Aetna/Humana case, where they';ve identified specific counties where they compete for Medicare Advantage and specific counties where they compete on the exchanges might be stronger partly because of the specificity and narrow focus.
The government is not talking on as big an issue, although the remedy they seek, which is to enjoin the merger, is exactly what they are seeking in the Anthem/Cigna suit.
They just haven't bitten off quite as much to prove. At the same time, it is possible that maybe a fix can be found to remedy this, although DOJ rejected the fix the parties offered.
HLM: Do you see any weaknesses in the government's cases?
Levine: DOJ doesn't explain how hard it is for any other insurer to get licensed to sell that product in those affected counties and how difficult it would be for them to develop a network.
DOJ just says they can't. The government didn't explain in the complaint why the barriers to entry are high enough that the merger will be able to accomplish the anticompetitive objective that the complaint alleges will happen.
HLM: Why isn't the Federal Trade Commission involved in this suit?
Levine: The division of labor in healthcare generally is that the FTC takes the healthcare services markets, the providers, doctors, and systems and the like. The DOJ takes health insurance markets. They both have jurisdiction to look at mergers that are filed.
U.S. Attorney General Loretta E. Lynch says allowing Anthem's acquisition of Cigna and Aetna's acquisition of Humana would restrict competition and give the merged companies 'tremendous power' over the nation's health insurance industry.
The U.S. Department of Justice on Thursday filed suit to block two proposed mega-mergers that would consolidate four of the nation's five largest health insurance companies.
"These mergers would fundamentally reshape the health insurance industry. They would leave much of the multitrillion-dollar health insurance industry in the hands of three mammoth insurance companies, and restrict competition in key markets," Attorney General Loretta E. Lynch said at a late morning news conference.
If the mergers were to go forward, Lynch said, the number of health insurance options for employers would shrink from four to three, the largest and fastest-growing providers of Medicare Advantage plans would combine into one company, and competition for individual plans on the public exchanges would be substantially reduced.
"If the mergers take place, the competition among the insurers that have pushed them to provide lower premiums and higher quality care would be eliminated," Lynch said. "The mergers may increase the profits of Aetna and Anthem, but at the expense of consumers across America."
Eleven states: California, Colorado, Connecticut, Georgia, Iowa, Maine, Maryland, New Hampshire, New York, Tennessee, and Virginia and the District of Columbia joined the department's challenge of Anthem's acquisition Cigna.
Eight states: Delaware, Florida, Georgia, Iowa, Illinois, Ohio, Pennsylvania, and Virginia and the District of Columbia joined the department's challenge of Aetna's acquisition of Humana.
Payers Reaction: Suit 'Misguided'
Anthem and Aetna issued statements protesting the suit on Thursday morning, even before Lynch made the public announcement.
"Today's action by the Department of Justice is an unfortunate and misguided step backwards for access to affordable healthcare for America," Indianapolis-based Anthem said.
"The DOJ's action is based on a flawed analysis and misunderstanding of the dynamic, competitive and highly regulated healthcare landscape and is inconsistent with the way that the DOJ has reviewed past healthcare transactions."
Aetna and Humana issued a joint statement vowing to mount a "vigorous defense" of their proposed merger.
"A combined company will result in a broader choice of products, access to higher quality and more affordable care, and a better overall experience for consumers," the payers said. "Aetna and Humana look forward to making this clear in court, where a judge will review the transaction based on its merits."
Providers Cheer Suit
American Medical Association President Andrew W. Gurman, MD, welcomed the suit and thanked the DOJ "for fighting to protect patients and physicians from a health insurance system dominated by a few corporate Goliaths with unprecedented market power. Patients are better served in a healthcare system that promotes competition and choice."
Gurman said competition in many health insurance markets is "already at alarmingly low levels" and that the federal government has an obligation to step in and enforce antitrust law.
"The prospect of reducing five national health insurance carriers to just three is unacceptable," he said. "Given the mergers' potential to significantly compromise market competition, the AMA strongly supports the antitrust challenge from federal regulators."
American Hospital Association President and CEO Rick Pollack called the suit "good news for consumers, who would have faced increased costs and fewer choices for coverage."
"Reduced competition in the insurance market threatens to increase the price and availability of coverage for all Americans in virtually every community. It would impede the progress our nation has made in providing affordable coverage to more people," he said. "Fewer coverage options for consumers also would undermine the hospital field's goal of keeping communities vital and healthy through continuous innovation."
Pollack said hospitals want to partner with insurers to transform care by making it more responsive to the needs of consumers, but that "all of the available evidence shows that as insurers get even larger, their willingness to innovate declines. That would be a setback that patients simply can't endure."
"DOJ made the right decision," he said. "We hope that it will also encourage insurers to become partners with the hospital field to further accelerate progress in access and affordability to better serve patients."
More than 90% of patients surveyed followed preoperative protocols to prevent surgical site infections. Researchers believe this inexpensive strategy will reduce SSIs.
A common sense-based by medical students at Washington University School of Medicine in St. Louis provides a good example of the benefits of patient engagement.
The research, led by second-year students Michelle Keyin Lu and Christopher Chermside-Scabbo, looked at patient engagement as a tool in reducing surgical site infection. It is the third most common healthcare-associated infection, adversely affecting more than 500,000 patients each year.
Lu, Chermside-Scabbo, and their student-colleagues measured the effect of an automated text and voice messaging system to improved communication with orthopedic surgery patients.
The daily prompts reminded the patients a week before their operations to use antibiotic skin ointments and body wash, and in the two weeks after surgery the daily prompts coached patients on the warning signs of infections, such as pain, redness, odor, and discharge.
Lu and Chermside-Scabbo presented their findings this week at the 2016 American College of Surgeons National Surgical Quality Improvement Program Conference in San Diego. The automated prompt system was developed by Epharmix, a healthcare information technology startup company founded by students from the Washington University School of Medicine.
Chermside-Scabbo and Lu are independent researchers at Epharmix, and neither holds a position in the company.
NSQIP encourages the use of preoperative antibiotics to decrease SSIs but only half of patients comply with the protocols. Relatively speaking, orthopedic procedures have a low SSI rate, ranging from 0.7 to 2.1 infections for every 100 cases.
Orthopedic surgery patients with SSIs, however, also have a two times higher rate of rehospitalization and a 300% increase in treatment costs.
High Rate of Patient Engagement
The automated text and voice prompts were tested on 430 orthopedic surgery patients at Washington University Barnes-Jewish Hospital. Of those patients, 96% responded to the pre-operative prompts and 90% responded to the postoperative prompts.
"We were surprised that it was this high," Chermside-Scabbo says. "We suspect that perhaps the nature of the surgery, being a big occasion that the patients take pretty seriously, could be a factor in that high response rate."
A post-event survey found that most patients believed the prompts improved communication with their surgeons; the median score was 8 on a scale of 1 to 9. Patients gave their overall care a 9.
And most patients said the prompts were easy to use and gave them confidence that they were doing the right things to help their recovery, made them feel cared about, and connected them to the patient care service.
"This isn't an application-based system," Chermside-Scabbo says. "A lot of healthcare systems are using their own proprietary apps that require the patients to download and log in. This system just needs a phone number. If it is an elderly patient and they don't have a phone, we can text; there is [also] a voice system they can use."
Effect on Infection Rates?
Of course, the big question is whether or not these audio and text prompts reduced SSI rates. Unfortunately, Chermside-Scabbo says the test group was too small to answer that question. They hope to have that question answered in their next series of studies.
"When we tried to power the study to show how many patients we'd need to really show a difference the number was in the thousands," he says. "That is why we chose to focus this study on the usability to make sure our message frequency was something the patients liked and that the response rates were adequate."
"Now we plan to move to other procedures that have higher complication rates historically, such as hip fractures, and specialties like colorectal surgery," he says.
"Instead of having SSI rates in the 3% to 5% ballpark, colorectal and other procedures have complication rates as high as 15% to 25%. In the coming months we intend to test that to show if our system can demonstrate a reduction in complications."
The Federal Trade Commission says consolidation of Cabell Huntington Hospital and St. Mary's Medical Center is anticompetitive, but shielded by state law from federal antitrust enforcement.
The Federal Trade Commission has decided to drop its challenge of the proposed merger between two Huntington, WVA hospitals, but not without a parting shot at a recently passed state law that made the "potentially anticompetitive" deal possible.
The commission last week dismissed its administrative complaint challenging the proposed merger between Cabell Huntington Hospital and St. Mary's Medical Center, two hospitals located three miles apart.
While maintaining that the merger would hurt competition in the region and result in higher healthcare costs, the commission dismissed the complaint on a 3-0 vote after West Virginia lawmakers passed a "cooperative agreement" with the hospitals, which was approved by the West Virginia Health Care Authority and the state's attorney general.
"This case presents another example of healthcare providers attempting to use state legislation to shield potentially anticompetitive combinations from antitrust enforcement," the Commission wrote in a statement.
"The Commission believes that state cooperative agreement laws such as SB 597 are likely to harm communities through higher healthcare prices and lower healthcare quality."
"If you harken back to some of the previous Supreme Court cases that dealt with state action doctrine, West Virginia passed legislation that empowered a government entity to oversee hospital consolidations and provided a mechanism to actively supervise it," says Levine, a disinterested observer.
"We can surmise the FTC thinks the state did a decent job to qualify for state action doctrine immunity to the antitrust laws, so the merger can't be challenged by federal antitrust authorities."
"They don't like when states try to do it. They don't think it's good for consumers or the healthcare industry and they made that displeasure well known, but nevertheless they have to face the reality that it would be an uphill battle to effectively challenge the merger," Levine says.
2 Steps Toward Immunity
To gain immunity, Levine says states have to do two things:
"Clearly articulate a state policy to displace competition. They usually do that through legislation."
"Provide a mechanism that the conduct is actively supervised by the state, the policy reason behind it being that to ensure that in fact what is being done is in compliance with the state desire to displace competition and nothing else."
The commission warned that its decision to drop the administrative complaint should not be interpreted as a retreat on antitrust enforcement in the healthcare sector.
"We will continue to vigorously investigate and, where appropriate, challenge anticompetitive mergers in the courts and, if necessary, through state cooperative agreement processes," the commission said. "Our decision to dismiss this complaint without prejudice does not necessarily mean that we will do the same in other cases in which a cooperative agreement is sought or approved."
Levine says it's hard to say if West Virginia is on the leading edge of a trend to sidestep federal antitrust regulations. "It really is a state-by-state issue," he says. "What is their political and economic philosophy? Do they want antitrust enforcement or do they want consolidations and cooperation?"
As a side note, the commission bristled at suggestions from West Virginia officials that the consolidation was needed because antitrust laws hinder care collaboration and coordination mandates under the Patient Protection and Affordable Care Act.
"This is fundamentally incorrect," the commission wrote. "The ACA did not repeal the antitrust laws, and it certainly does not condone mergers that substantially lessen competition."
"You can almost hear the frustration in these statements," Levine says. "Time and again the parties defend their actions arguing that the ACA, if it is not compelling their activity, at least promoting it, and that they can't be faulted for trying to comply with the goals of the ACA."
"The FTC continues to come back with the argument that the ACA does not mandate, compel, or recommend anticompetitive activity and that there are all sorts of collaborative associations that can be implemented that do not run afoul of the antitrust laws," he says.
"There is this ongoing battle. The mantra on either side is not going to change."
The Philadelphia-based academic medical center is building a 'hub-and-hub' health system that provides care in lower-cost community hospitals and pushes value over volume.
Traditional hospital mergers and acquisitions create a hub-and-spoke model. The hub hospital, usually a large urban acute care or academic medical center, picks up surrounding community hospitals, often financially stressed, to build a regional referral network and—often left unsaid— to create a larger footprint to improve leverage with payers.
Stephen Klasko, MD, president and CEO of Jefferson Health, says the Philadelphia-based health system is turning that model upside down and creating a delivery system that aims to treat patients in the communities where they live.
By acquiring financially sound community hospitals and providing care in those less-expensive settings, Klasko says the Jefferson Health model can avoid the increases in the cost of care that usually occurs when hospitals consolidate.
"It is asinine to believe that, if you are an academic medical center that's trying to bring in troubled community hospitals so they can send more patients to your expensive hospital downtown, prices will go down," he says. "Our model is 180 degrees from that."
Last week, Jefferson Health finalized its acquisition of the three-hospital Aria Health system, coming a little more than one year after the acquisition of Abington Health.
The combined system includes eight hospitals, 32 outpatient and urgent care facilities, and dozens of physician practices, and about 23,000 employees, all of which is governed by a board trustees that has an equal number of representatives from the academic medical center and the various community hospitals.
"The control is literally across the entire enterprise," Klasko says. "The vision of the board is to look for what is best for the community rather than what is best for downtown."
Jefferson is also in the process of acquiring Kennedy Health, a three-hospital system serving southern New Jersey.
"One thing that is different about our model is that all of our mergers have been shared governance, hub-and-hub mergers with other systems that didn't need to do anything," Klasko says.
"We don't even respond to someone who says we need $200 million to survive."
Keeping Patients in Their Communities
Former Aria CEO Kathleen Kinslow says the health system went into the merger with a "goal to keep patients in their communities."
"When we were going through the process, two things that we had in the forefront were to be able to maintain our mission and to serve patients where they live. Bringing the expertise of an academic medical center into the community allows that to happen," says Kinslow, now the executive vice president and chief integration officer at Jefferson.
"Through the integration process, one of the things as we bring the service lines together is to look at total cost of care. At Abingdon and Aria, based on where we are geographically, the cost of care is lower. Instead of transferring patients to the city hospital, it's keeping them in the community and developing those protocols and systems that need to surround care pre- and post-operatively, and what you need to do in the community will all be continued to be developed."
"The metric we will continue to look at is total cost of care and quality outcomes," Kinslow says. "You can have low cost of care but poor outcomes that wouldn't be advantageous. All organizations have a strong commitment to quality and safety."
Klasko says Jefferson has demonstrated a history of success in population health and cost containment with its participation in the Delaware Valley Accountable Care Organization, a Medicare shared savings program.
"We were one of the top five or six receivers of dollars for quality/cost ratio in the last go around with (Centers for Medicare & Medicaid Services)," he says. "The fact is we are investing lots of dollars investing all the things you ought to do in going from volume to value while frankly some others are doubling down on the old way, and that is why costs haven't gone down."
As for consolidation restricting competition, Klasko says that doesn't apply to Jefferson.
"The beautiful thing about Philadelphia is we have six academic medical centers within walking distance of each other," he says. "We'd have to get a hell of a lot bigger to worry about that."
