Having noticed that "the majority of tests we were ordering… really didn't impact the day-to-day care," a group of neurosurgery residents identified five lab tests that could be eliminated without affecting patient safety. They generated nearly $2 million in savings, including $75,000 in direct costs for their medical center.
Seunggu J. Han, MD, is a neurosurgeon
at UCSF
Neurosurgery residents at the University of California San Francisco Medical Center have demonstrated that a reduction by nearly 50% in the use of five common lab tests has no effect on patient care. The reductions generated $1.7 million in savings for payers in fiscal 2011–12, and another $75,000 in decreased direct costs for the medical center, according to a study in Journal of Neurosurgery.
In theone year before the project, the residents identified 45,023 of tests for serum levels of total calcium, ionized calcium, chloride, magnesium, and phosphorus in the neurosurgical service. In fiscal year 2011–2012, this number was reduced 47% to 23,660. The residents' findings were part of an in-house initiative at UCSF that encourages clinicians to identify department-specific cost savings and quality improvements in care delivery.
Seunggu J. Han, MD, a lead researcher among the 18 residents in the project and a neurological surgeon with UCSF, says it makes sense that residents would lead cost savings and quality initiatives because they're often the front-line clinicians with the most contact with patients.
"As a group of residents, we picked up that the majority of tests we were ordering on the neurosurgery service really didn't impact the day-to-day care," Han says. "No clinical decisions were made based on those lab results, whether they were normal or not. The patient's care would not have changed at all whether we had done that test or not. That was the case particularly with those lab tests that we identified."
Han says the high numbers of tests were conducted because UCSF is a high-volume tertiary referral center for neurology that sees more than 2,000 patients a year, many of whom are housed in the intensive care unit, where the assumption is that they are critically ill.
"They are in some ways [critically ill], but probably not in the typical ways that a medicine patient in the ICU would be. They don't tend to have the same gamut of medical problems that the typical internal medicine service would see," he said.
"There is a habit in the ICU setting to order a lot of labs and daily labs just to see if anything is abnormal because there is this assumption that these patients are critically ill and any number of these lab tests can go wrong at any point."
"We were looking at the numbers of labs that we were actually ordering on the service and it is quite an astounding number as a product of the ICU as well as the sheer number of patients that we actually see on the service. You can imagine that compounded with a three-day ICU stay for the typical patient who is getting daily labs. That adds up to be quite a large number," Han said.
The residents worked with an internist who coordinated care with the neurologists and they identified the typical neurology patient and the standard lab tests they'd ordered. Han says they found that the five tests they most frequently ordered came back with normal results "the vast majority of the time. Not only that, but the times they were abnormal we had a very good reason why it was expected and it didn't impact our clinical care. We identified that as a potential area where we could make a significant impact in reducing the lab tests."
Criteria for testing and quality metrics set
Han says the residents weighed the safety of the patient against the need for a test. They didn't want patient care to suffer for lack of a diagnosis. "We were being careful about ordering it on everybody, to really be smarter about who we are ordering it for and almost predicting based on the patients past medical history and their current medical condition who are the patients we should be ordering for and who has the higher likelihood of an abnormal test."
"We met with our hospitalist group and came up with criteria. If the patient meets this criteria that would be the only scenario where would order these tests. We also monitor and have a quality and safety review board that follows all of the general outcomes of these patients including readmission rates and length of hospitalization and length of time in the ICU. Those quality metrics that we followed over time hadn't changed at all throughout this period where we were implementing the new policy of reduced lab orders. We were reassured that we actually had not diminished the quality of the care that we were providing. We didn't see higher rates of complications because a lab test was missed or failed to be ordered or failed to detect an abnormal test."
High expectations vs. unknown factors
While reducing the tests by 47% is an impressive achievement, Han and his fellow residents had pledged to reduce that amount by 50%. "We were just shy of that 50% reduction and the lesson we learned was that it is hard to make changes like this. When you set a goal that takes a lot of effort and foresight and when you are trying to implement these goals there are a lot of unknown elements that you don't always know about going forward," Han says.
"As a group of residents, one of the unknown factors we encountered was there were a lot of lab orders that we don't have control over. On our service the anesthesiologists help us take care of the patients and have the ordering privileges to order any kind of labs on their patients that they deemed appropriate around the operative and perioperative care settings. All the labs they ordered in some ways counted against us but they certainly felt it was an important part of the care so we never argued. That was probably what was included still in that group of 53% of tests that were still being ordered."
Even though they generated nearly $2 million in savings, including the $75,000 in direct costs for the medical center, the residents were not awarded the $400 prize from UCSF. Nonetheless, Han says they are all "very proud of our results."
"We were actually surprised that it wound up calculating out to be a fairly large sum of money," he says. "The medical center did thank us for our efforts at the quality retreat for the medical center they gave us the award for the best quality improvement initiative initiated by physicians."
Impact beyond neurosurgery
Han believes the saving generated by the neurosurgical residents can be replicated throughout hospital care delivery, especially if hospital leaders encourage innovation and problem solving.
"Quality improvement and improving the efficiency of the hospital for every kind of service is an ongoing process. There are always areas to be improved upon and the hospital setting is such a large system and such a big machine that there are bound to be inefficiencies and areas where the quality of care being delivered that could be improved," he says.
"It is an important part of the training process, particularly for residents to get an exposure to this process early and having an eye out for recognizing where there are areas of need for quality improvement and really having the awareness of knowing how to implement a project and monitor the progress and carry it through and seeing its results."
Rates of hospital-acquired pressure ulcers vary widely in hospitals based on how the data is collected, researchers say. In one study, surveillance data identified 10 times more pressure ulcers than billing data.
Hospitals that rely on claims data to measure hospital-acquired pressure ulcers are likely under-reporting the problem and creating an inaccurate comparison with competitors for the public. A far more accurate measure uses surveillance reports by trained clinicians inside the hospital, a new study shows.
A University of Michigan School of Medicine study, which appears this week in the Annals of Internal Medicine, found that HAPU rates varied wildly in hospitals based on how the data was collected, inaccurately making some hospitals appear to be better or worse than peer institutions.
The UM study examined two million all-payer administrative records from 448 California hospitals and quarterly hospital surveillance data from 213 hospitals in that state that were publicly reported on CalHospitalCompare in 2009. The researchers winnowed the sample to 196 acute care hospitals with at least six months of claims data and surveillance data.
Jennifer A. Meddings, MD, an internist and pediatrician at UM and the leader author of the study, says researchers "looked at the same hospitals in the state of California in the same year and mapped criteria looking at the same patients as much as possible and the same severity of ulcers."
"The surveillance data found 10 times more pressure ulcers than the billing data. That is a big problem. We expected the surveillance data to be a little bit higher but not dramatically higher," she says. "The one thing we had hope for was 'are we still able to track the same hospitals that are bad performers. Are the same hospitals with high rates in surveillance data the same hospitals we would have identified by the billing data?' Unfortunately this was not the case."
Meddings says the process by which claims data is collected is not conducive to accurate reporting of HAPUs.
"Hospital coders are not clinicians and they are basically restricted by federal rules as far as what types of papers they are even allowed to look at to get the pressure ulcer diagnosis," Meddings says. "The surveillance data is quite different and generated by a team of nurses and other specialists who are trained specifically on how to examine a patient head to toe, a full skin exam to look for pressure ulcers, how to stage them correctly, how to figure out if they were hospital-acquired or not, and how to differentiate bed sores from other types of skin problems."
Specialized clinical surveillance teams in California examined every patient in the hospital at least once every quarter or more frequently and detailed their findings through a standardized public reporting process with the state.
"Not only did they examine the patients, they were allowed to look at the entire medical record, the doctors' notes, the wound care specialists' notes, the nurses' notes," Meddings says. "They had all the data and they were looking at the patients with their own eyes, which is quite different as opposed to the billing data."
The study's HAPU findings are consistent with a similar review Meddings' team conducted last year of catheter-associated urinary tract infections at California hospitals.
"We know the use of the catheters and skin conditions is much better documented in nurses' notes rather than doctors' notes because nurses are providing much of the skin care and they routinely do the skin exams and they are also the providers who place and monitor the urinary catheters," she says. "Both of these complications are essentially easy to find in nurses' notes, but very hard to find in the notes that coders are allowed to look at."
Continued use of claims data as a measure of hospital HAIs also misinforms the public. "One of our biggest concerns is that there seems to be a trend of quickly using data to publicly report because the data is available and only asking questions years later of whether or not their data is accurate. These types of assessments should have been done before the data was publicly released," she says.
"Frankly, the way the data is collected, if a physician in a hospital is actually very diligent about documenting these issues, then it is more likely to end up in the billing data, so you are actually having an unintended consequences of penalizing the hospitals that document better and reward hospitals with incomplete documentation. If you do an incomplete job of documenting these complications they will never show up in your billing data."
"The data we actually used to do this assessment was available when this policy was being implemented. These types of assessments could have been done before they chose the policy, but then it's a different approach for using the data and we prefer validating the data before using it for this purpose, rather than using it until somebody proves that it is wrong."
Meddings says Medicare and other payers need to adopt a more systematic reporting process that relies less on claims data. "We like the use of the surveillance data in California. We recognize it can be an expensive process, but probably something like a modification of what they're doing would standardize validated measures."
It shouldn't take an IOM recommendation to ban ghostwriting, and yet one-third of medical schools still allow it. Why aren't all medical colleges in compliance with the fairly straightforward clinical conflict of interest policies set forth by four prominent medical associations?
And yet a report in the October issue of Academic Medicine that examines clinical conflict of interest policies (CCOI) at the nation's medical colleges finds that while progress is being made, these hallowed training grounds for the physicians of tomorrow remain lax at teaching them about inappropriate behavior.
For example, the Institute for Medicine as a Profession review found that nearly one-third of medical colleges still have no prohibitions on ghostwriting. Nearly two-thirds of medical colleges still lack policies to limit ties to industry, including gifts, meals, drug samples, industry-funded continuing medical education, and payments for travel, consulting, and speaking.
Only 16% meet national standards in at least half of the areas, and no school met all the standards.
None.
"We actually have these standards," Susan Chimonas, lead author of the study, associate director of research at the Center on Medicine as a Profession at Columbia University, told me in a recent interview. "We've had three independent bodies of experts coming to basically the same conclusion about what these policies should look like or involve. Several years have gone by now and many schools are not coming even close to meeting those policies."
Some progress
In fairness, let's acknowledge that progress is being made and that many needles are pointed in the right direction. The survey examines CCOI policy changes from 2008–2011. As reported this week, in 2008, "no policy" was the most prevalent finding in all but one CCOI area. By 2011, the number of schools with no CCOI policies dropped from more than one quarter in 2008 to less than 2% in 2011.
Of the 12 areas examined for CCOI the survey found that the number of medical colleges in the "moderate" range more than doubled, from 14% to 30%, while the number of schools with strong policies in eight or more areas barely increased, from 1% in 2008 to 4% in 2011. Eighty-four percent of schools had substandard policies in seven or more areas.
Based on the progress demonstrated from 2008–2011 CCOI policies have gotten more stringent in the past two years that were beyond the IMAP review.
What's the delay?
While we can acknowledge successes, it is also fair to ask what's taking so long. Why aren't all medical colleges in compliance with these fairly straightforward CCOI policies? This is not a cure for cancer. It's a policy change that could be implemented with a pen stroke.
Yes, some relationships between physicians and medical device companies, pharmaceutical companies, and other businesses are legitimate and valuable and serve a public good. For the most part those sorts of relationships can be identified, defended and exempted from CCOI action.
Other CCOI practices are obviously wrong and should have been banned years ago. It shouldn't take an IOM recommendation to ban ghostwriting, and yet one-third of medical schools still allow it. Ghostwriting is either plagiarism, bribery, or both.
Accepting money or other compensation to shill for medical research that someone else did is worse than plagiarism because physicians are cashing in on their profession's hard-earned credibility and public trust to hawk a product. The actions of a few physicians who violate this public trust harm the reputations of the vast majority of physicians who do not.
Heather Pierce, senior director, science policy for the Association of American Medical Colleges, said in an email exchange with me that national transparency initiatives such as the Physician Payment Sunshine Act are spurring dialogue in medical colleges about the value of more-stringent CCOI policies.
This is encouraging. It is also unfortunate that medical schools may be motivated by fear of disclosure and public embarrassment to adopt common-sense CCOI standards and not because it's the right thing to do.
Healthcare leaders surveyed for a recent HealthLeaders Media Intelligence Report cite 30-day readmissions as the clinical quality metric that presents by far, their greatest challenge. We talk with four hospital health system leaders about their strategies for reducing readmissions.
What makes that such a tough challenge and how can leaders effectively meet that challenge?
Thomas A. Selden
CEO
Southwest General Health Center
Middleburg Heights, Ohio
On meeting the challenge:
I don't think it's our "greatest challenge." It is one we have been very successful in dealing with. We are a $300 million operation with $120 million of Medicare net revenue. Our readmission penalty in 2013 was $250,000. We have reduced that to $60,000 for 2014. Because they are grading on the curve, the winners and losers, you have to move with it or fall behind. If we had the same position on that bell curve measuring this year, it would have resulted in a penalty next year of $500,000.
On collaborative problem solving:
We take a multidisciplinary approach to solving problems. We identified components of the health system that impact readmissions and decided that we needed a seamless transition of care across the continuum. We have monthly meetings with the multidisciplinary team that reviews the strategies we have implemented and the metrics we have achieved. We implemented a care coordinator on each of the patient units who works with the doctors and nurses to ensure that the process is going smoothly and the patient is getting ready for discharge and knows what they need to know when they leave.
On collaborating with outside partners:
We serve an older population so we collaborate with area nursing homes with a monthly meeting sharing best practices, practice guidelines, and patient education information. We give them a report card on how they are doing in managing the patients pre- and postdischarge. We're trying to streamline patient information for the nursing homes so they know what is going on in the hospitals and they can pick up the chain from there.
Charles Derus, MD
Vice President of Medical Management
Advocate Good Samaritan Hospital
Downers Grove, Ill.
There is a lot we have done at our hospital to reduce readmissions rates. When we looked into it we found not surprisingly that somewhere in excess of 20% of patients discharged to a skilled nursing facility were being readmitted within 30 days. We worked with our local nursing homes, set up a skilled nursing facility council and started to share some information and best practices around reducing readmissions. We brought that rate down to 14% in a year and a half. It was just sharing information about why people were coming back.
One of my other roles at Advocate was in a multispecialty group practice. They had put together a robust ambulatory management program for people with diabetes that focused on ambulatory care and improving transition in handoffs really reduced the readmission rate in that population as well. We at the hospital are pioneering with outpatient care managers embedded in physicians' offices to try to better manage people with chronic diseases and improved transitions. We have seen some early reduction is readmissions from improving both transitions and ambulatory care.
There is also a very clear connection between complications in the hospital for surgical patients and subsequent readmissions. Although some readmissions cannot be prevented there is a sizeable number that can be prevented and we just have to do things differently.
Mina Ubbing
President and CEO
Fairfield Medical Center
Lancaster, Ohio
The toughest challenge is that the penalty goes to the hospital provider but the control over what happens to the patient is dispersed among a number of places.
We have been working closely with our local healthcare network, which includes skilled nursing facilities, home care agencies, or long-term acute care facilities, and our community health center. Some of the challenge is getting the patient seen for follow-up with a primary care physician. We have two primary care residency clinics that we make available for that patient who either does not have a primary care physician or who can't be seen in a timely manner to try to alleviate that part of the problem.
We have worked with our nursing homes, with some of the specific diagnoses that this covers but more generally to make sure that their skills and talents are optimized in the care of specific patients. We work with our emergency room physicians. We work with our hospice agency collaboratively. I have heard ideas about collaborating with ambulance companies to do some quick triage as to whether the patient really needs to come to the hospital or if there are other stabilization opportunities that can be provided.
Thomas Foster
CEO
Bucktail Medical Center
Renovo, Pa.
It is a challenge primarily because we are a critical access hospital in a very rural part of the country. Those 30-day readmission rates are the element over which we have very little control. We are the only provider of healthcare services in a 25-mile radius. We aren't subject to a punitive action at this point. It is coming. It is going to be part of our quality metrics and that piece is going to be one of those things that we have to do a better job at managing the patient outside of the facility.
We can provide the community information. We can provide all of the resources. But at times you can lead a horse to water but you can't make it drink. With those preventive programs, it's definitely going to help us head off some of this, but not necessarily be one of those things that we are going to effectively manage.
One of the things we are preparing to do is to be able to build into our contractual allowances the idea that there are going to be cases where we are not going to get reimbursed. We project reserves for bad debt and for uncompensated care and it's going to be a part of that factor. It's unfortunate, but it's just one of the challenges we are faced with.
Not-for-profit hospitals could see a migration of commercially insured patients to exchanges, where reimbursement rates may be lower, says a report from Moody's Investors Service. Commercial rates have traditionally subsidized Medicare losses and driven profitability for most hospitals.
Unanswered questions about health insurance exchanges such as who will enroll and what exchange-based plans will pay providers will create a "modest credit negative" for not-for-profit hospitals in 2014, Moody's Investors Service says.
The Congressional Budget Office has estimated that about seven million people will sign up for health insurance coverage under the exchanges. However, Moody's Associate Managing Director Lisa Goldstein says in a new report that NFP hospitals could see a migration of commercially insured patients to exchanges, where reimbursement rates may be lower.
"The exchange-related risks center on two primary issues that will largely negate the benefits of a declining uninsured population in 2014," Goldstein said in remarks accompanying the report. "These issues are the level and composition of enrollment, and how insurance exchanges exacerbate revenue pressures on hospitals."
"Providers are reporting that negotiations with exchange plans range from Medicaid rates, usually the lowest rate-per-service a hospital receives and does not cover costs, to a discount off of commercial rates, typically the highest rate a hospital receives," Goldstein said. "Commercial rates subsidize losses incurred with Medicaid and Medicare and drive profitability for most hospitals."
A Rise in Bad Debt
Another pitfall for NFP hospitals is the "timing mismatch" between the savings that hospitals should expect sometime in the future for treating fewer uninsured patients, and real reimbursement cuts that went into effect on Oct. 1 for Medicare, Medicaid, and Medicaid disproportionate share payments [DSH] for safety net hospitals.
Goldstein said bad debt likely will rise because new enrollees previously insured by a commercial insurer are likely to sign on to plans with high co-pays and deductibles, which they may ultimately be unable to pay. Moody's also expects some delays in payments and processing claims among exchange-based insurers because they will tend to be smaller and less experienced, and will take time to come up to speed.
In addition, private health insurance exchanges that are not part of the Patient Protection and Affordable Care Act are expected to become more popular with private employers looking to reduce healthcare benefits. Goldstein says reimbursements from insurers on private exchanges are expected to be lower than those from commercial insurers.
The nation's largest hospital associations have supported the PPACA, but have also raised concerns about the unintended consequences and potential financial burdens that hospitals could face during the implementation.
Rates Unknown
Xiaoyi Huang, vice president for policy at America's Essential Hospitals, says safety net hospitals don't know yet what the exchanged-based plans are going pay.
"All of our member hospitals are essential community providers and there is some language in the ACA about rates that all of the health plans have to pay essential community providers but it is very broad language," she said.
"Beyond that, it is up to the individual providers to negotiate with the plans depending upon who has the better budgeting position to figure out how much of their costs are covered through the rates. But honestly we don't know what that rate is."
"We care about whether our hospitals are included in the networks of these plans just because if you are not in the networks, you are automatically off to a disadvantage. But even for those that are included, we at this point don't have a systematic sense of what types of rates are being offered. We hope it is not as low as Medicaid because then you are just trading one form of uncompensated care for another."
Ellen Pryga, director for policy at the American Hospital Association, says hospitals are trying to predict the effects of a broad set of factors.
Data Needed
"The reality is none of us really know how it is going to shake out until we begin to get some data out of the various exchanges in terms of who is enrolling and what level plans they are enrolling in, etc…," she says.
"There are some other things that we have been looking at that we think are going to play a role too. For example, we think that some of the really heavy initial push to enroll will be for people who have pre-existing conditions. The Pre-existing Condition Insurance Program capped out and stopped enrolling people almost a year ago. So people with pre-existing conditions are likely to be some of the first in line here and people with pre-existing conditions use a lot of services."
Pryga says hospitals are also trying to figure out how insurance market rules that go into effect on Jan. 1 could affect providers' bottom lines.
"For example, one thing that goes away is the annual limits on the amount of benefits that get covered during the year. Another thing that happens is the implementation of out-of-pocket limits under all of those plans, not just in the exchanges but outside of the exchanges as well," she says.
"All of those plans, whether they are individual, small group, large group or self-insured are going to have out-of-pocket limits on cost sharing. So, the combination of the removal of the annual limits and the limits on out-of-pocket expenditures, while they differ for those groups, is going to be an effect."
Delay Sought for DSH Cuts
Huang and Pryga say their associations have been pressing the Obama administration and the Department of Health and Human Services to postpone the DSH reimbursements because of the timing lag, and also because more than 10 states have rejected the Medicaid expansion, which negates the trade-off in states that reject Medicaid expansion.
"If your income is below 100% of the federal poverty line you are not eligible for any subsidies through the exchange and in many states the Medicaid eligibility level is like 30% – 40% of the federal poverty level," Pryga says. "You can have a pretty substantial gap between the Medicaid eligibility and the eligibility for subsidies through the exchange in the absence of Medicaid expansion."
Huang says DSH payments "prop up a lot of our hospitals."
"It doesn't cover 100% of the costs but it does a really good job of offsetting some of the uncompensated care that these hospitals take on. Given all of the uncertainty we think it makes sense for the DSH cuts to be delayed until the administration has data to see what that take up looks like. Even with the data limitations it is going to be a two- to three-year lag between fiscal 2014 and when the data will actually show fiscal 2014 performance."
While medical schools have had clear guidelines for conflict of interest policies since 2006, many fall short of meeting the policies set forth by the Association of American Medical Colleges, the Institute of Medicine, and others, research shows.
The nation's medical schools have made progress over the last five years developing clinical conflict of interest policies but they all still have a long, long way to go, a study shows.
Institute for Medicine as a Profession researchers compared changes in medical schools' policies from 2008 to 2011, and found that while many institutions made progress implementing some COI policies, nearly two-thirds still lacked policies to limit ties to industry, including gifts, meals, drug samples, and payments for travel, consulting, and speaking. Only 16% met national standards in at least half of the areas, and no school met all the standards.
"It is a good news-bad news situation," says Susan Chimonas, lead author of the study, associate director of research at the Center on Medicine as a Profession at Columbia University. The study appears in the October issue of Academic Medicine.
Chimonas says medical schools have a clear blueprint for conflict of interest policies that have been put forward since 2006 by groups that include the Association of American Medical Colleges, the Institute of Medicine, the American Board of Internal Medicine Foundation, and IMAP.
"That is the thing that is interesting to me," she says. "We actually have these standards. We've had three independent bodies of experts coming to basically the same conclusion about what these policies should look like or involve. Several years have gone by now and many schools are not coming even close to meeting those policies."
The study notes that in 2008, "no policy" was the most prevalent finding in all but one CCOI area. By 2011, almost all schools had made strides, and the number of schools with no policies dropped sharply from more than a quarter in 2008 to less than 2% in 2011.
Policies in the "moderate" range more than doubled, from 14% to 30%. However, the proportion of schools with strong policies in eight or more areas barely increased, from 1% in 2008 to 4% in 2011. Less-than-stringent policies remained typical for all areas except ghostwriting. Eighty-four percent of schools had substandard policies in seven or more areas.
Chimonas says her study doesn't ask why the schools aren't moving more quickly on conflict of interest policies, but she speculated on the reasons.
"Maybe there is faculty resistance," she says. "Physicians might like getting the gifts and the payments. So it could be a difficult thing for schools to move forward and implement these things. It could also be institutional resistance. Medical schools have a lot of other things on their plate that are maybe more urgent on a day-to-day basis. So maybe this isn't a priority for them yet."
"There are many reasons we could think of for why progress isn't being made more quickly. The point we can agree on is that more progress needs to be made and we have to figure out how to help or encourage schools to move forward from this point on."
The top five medical schools that came closest to meeting the national CCOI standards were:
Emory University School of Medicine
University of Massachusetts Medical School
University of Iowa Carver College of Medicine
Boston University School of Medicine
University of Arkansas for Medical Sciences College of Medicine
Among schools with the weakest policies:
Saint Louis University School of Medicine
George Washington University School of Medicine and Health Sciences
Weill Cornell Medical College
University of Nebraska College of Medicine
Case Western Reserve University School of Medicine
Heather Pierce, senior director, science policy for the Association of American Medical Colleges, says AAMC is "pleased" with the progress that medical schools have made in the last few years to strengthen COI policies.
"As the study notes, the progress that institutions have made since the AAMC task force reports outlining recommendations for COI policies that strike a balance between appropriate, principled partnerships with industry and protecting the integrity of clinical care decisions is encouraging," Pierce said via email.
"We are encouraged by the robust and continued dialogue surrounding these issues. These discussions have also been spurred by national transparency initiatives such as the newly implemented rule on financial conflicts of interest in federally funded research as well as the information that will be available to the public through the Open Payments database of payments made to physicians and teaching hospitals under the provisions of the Affordable Care Act known as the Physician Payments Sunshine Act."
Chimonas says effective conflict of interest policies are needed to maintain public trust in the medical profession.
"It is important for patients to know and feel confident that the care they are getting isn't influenced by pharmaceutical marketing interests," she says. "When you go to your doctor you want to know that he is giving me this prescription or recommending this treatment because it's the best thing for me and not because he gets $50,000 a year to read a speech that was written for him by a pharmaceutical company, or because last night he got a $100 dinner paid for by another company."
"It is also important at a broader level that the public, all of us together, that we have trust in the medical profession. This is a profession that we all look up to. It's not just individual doctor that you look up to. It's the whole profession. We want to have confidence that the profession is regulating itself properly. We rely on the medical profession."
The study also analyzed whether a school's status, hospital affiliation, or source of funding influenced CCOI policy strength. Although hospital ownership and public or private status had no impact, medical schools with greater funding from the National Institutes of Health were more likely to have stricter policies than those with less funding.
To track progress and encourage stronger policies, IMAP has launched a new Conflict of Interest Policy Database that houses policies from medical schools across the country. The publicly accessible database allows anyone to search a school's CCOI policies, compare them with other institutions, identify where progress needs to be made, and learn best practices, Chimonas says.
As a reward for that longstanding public trust, Chimonas says physicians are given leeway to self-regulate. "It is unfortunate that we've got this set of standards, there is a consensus by these three expert bodies," she says. "And yet the schools that are in a position to actually implement some things that would show that the medical profession is serious about getting this right, that it is too slow, it's not going quickly enough, and this really jeopardizes the public trust."
If medical schools don't act more assertively to install conflict of interest policies, Chimonas says they could risk an unwanted intervention by an outside entity such as the federal government.
"It is something that would be much better if the medical profession did it instead of the federal government. Government is a blunt instrument and it is important that this be done right because some of the relationships between doctors and companies are positive," she said.
"We want to make sure we have the right balance and medicine is in the best possible position to know what that balance is. I am wary that if this doesn't get done well within a reasonable time frame that something could come down from an outside body. That concerns me but on the other hand maybe the threat of that will help the schools move more quickly."
The 7% growth in physician executive compensation across all titles between 2010 and 2012 is consistent with growth seen in the previous two-year period, but down significantly from the mid-2000s.
Compensation for physician-executives increased in the past two years but at a much slower pace than five or six years ago, a survey shows.
The more than 2,300 physician-executives responding to the 2013 Physician Executive Compensation Survey by Cejka Executive Search reported a median total compensation of $325,000, up 7% from $305,000 reported in the 2011 survey.
The results were better in the C-Suite, where chief quality/patient safety officers reported compensation increases averaging 22% and other C-Suite executives reported increases averaging 25%.
"Physician executive compensation really reflects the slowness of the economic recovery and we believe the uncertainty of healthcare and healthcare reform. It kind of goes hand in hand," says Paul Esselman, executive vice president, managing principal at St. Louis-based Cejka.
"We saw an average for all physician executive compensation of about 7% between 2010 and 2012 across all titles. That is consistent with our survey that we did the previous two years, 2008–2010, but it is far behind what we historically saw back in the mid–2000s of 12% plus growth."
A further breakdown of the survey data showed that physician-executives spend an average of 68% of their time on their administrative responsibilities, with 26% spent on clinical work, and 3% on research. Within the C-Suite, that allocation is much higher, with chief medical officers averaging about 89% of their time on administrative duties.
"We are seeing more physicians enter into the top C-suite roles," Esselman says. "You are seeing them as CEO, chief integration and chief strategy officer; the top-level positions within organizations that are helping to drive the strategy. We are seeing those numbers grow every year. The reason why we will see compensation increases for physicians is simply because physicians are getting into more of those positions of greater responsibility, especially when they are looking at quality, safety and patient satisfaction, everything that drives the success of the organization."
It also appears that the time spent on administrative duties is reflected in the paycheck. Esselman says median compensation for administrative duties for all physician executives went from $39,944 for those spending 25% or less of their time in administration to $340,000 for those who allocated 100% of their time. C-suite executives spending 100% of their time on administrative duties reported the highest median compensation, $535,000.
Physician-executives holding post-graduate management degrees saw a 10% difference in median compensation when compared with their physician colleagues with no post-management degrees. The difference is even more pronounced at the C-Suite level, with a 7% to 28% difference in median compensation between those holding a master's in business administration and those with no post-graduate management degree.
"We have continually seen more and more physicians seek those degrees in all of our surveys," Esselman says. "For physicians, especially the younger generation of physicians who are just getting started in their leadership career, this is very important. It will be a good return on investment."
In the coming decade Esselman says he expects that physician-executive compensation will steadily increase even amid the uncertainty of healthcare reform as the payment models shift away from volume and toward quality, safety and patient satisfaction.
"The satisfaction is not only for the patients but the caregivers, nurses, physicians, etc. That is going to be the focus going forward," he says. "We will certainly see more at-risk compensation, how an organization does in those areas. Not that the financial performance isn't going to be important, but many health leaders feel that if they have good quality, great safety and excellent service, meaning patient satisfaction, the patients and the finances will follow."
It's not all gloomy news for healthcare in the Sunshine State. The governor has earmarked $20.6 million in state funds that when coupled with existing Medicaid funds, will provide $80 million in supplemental funding to create a Statewide Medicaid Residency Program.
Politicians in Florida have taken a lot of well-earned criticism for their decision to reject about $51 billion in Medicaid expansion money made available under the Patient Protection and Affordable Care Act.
You don't have to embrace "Obamacare" to understand that this is a political calculation that is dumb, short-sighted, and hurts as many as one million of the most vulnerable and powerless people in the state.
But it also won't save money. The demand for uncompensated care will continue and the cost will continue to be shifted to people with health insurance. Caregivers will eat the balance.
On other fronts, Florida Gov. Rick Scott, a one-time CEO at Columbia/HCA, made headlines recently for his staunch opposition to a state-sponsored health insurance exchange and for actively hamstringing the federal exchanges that simply provide a venue for people to buy coverage from private sector plans. Again: dumb and short-sighted. Why would any elected leader hinder people from buying private healthcare coverage?
But it's not all gloomy news for healthcare in the Sunshine State. Gov. Scott has earmarked $20.6 million in state funds that when coupled with existing Medicaid funds, will provide $80 million in supplemental funding to create a Statewide Medicaid Residency Program.
Until now, GME funding in Florida was limited to a few hospitals and was provided as part of per diem payments to those providers with established residency programs. Now, the funding will be available for any hospital—urban, suburban, rural, large or small—that agrees to sponsor a residency program.
Liz Dudek, secretary of Florida's Agency for Health Care Administration, said in prepared remarks that the program "will improve access to and quality of care for all Floridians, expand graduate medical education on an equitable basis, and increase the supply of highly trained physicians statewide."
This has potential because we all know the challenges that underserved areas in urban and rural settings face when trying to attracted clinicians. We also know that one of the best ways to bring physicians and other highly skilled clinicians into underserved areas, and to keep them there, is to first bring them in as residents.
It's not immediately clear how many hospitals will take advantage of the new funding, or how many are in a position to consider establishing a residency program. Even with supplemental funding residency slots aren't cheap to establish and maintain. However, the program and the money behind it at least signal an awareness from political leaders that Florida has a physician shortage and that something needs to be done.
Joseph Portoghese, MD, chief academic officer at Florida Hospital, says the Orlando-based health system is expected to get about $3.2 million under the state's residency program. It's not clear how far that new money will go to defray costs for the system's 150 or so residency slots.
"We already operate at a deficit for medical education that dwarfs that amount," Portoghese says. "It certainly helps us, but we really have not sat down and decided if we are going to create additional residencies or enlarge our existing residencies just yet."
Still, Portoghese says any new sources of funding are critical because funding under indirect medical expenses through Medicare is expected to diminish in the coming years.
"Even if you happen to have residency programs that are funded from the federal government through [the Centers for Medicare and Medicaid Services] that funding is only based on the proportion of your admissions that are Medicare, so you never get full funding. You are always short in resident salaries and expenses when you are involved in medical education," Portoghese says.
With few other funding sources, Portoghese says many hospitals simply absorb the cost of training the next generation of physicians. "But it certainly would be helpful to us and society at large if others stepped up and helped fund the costs of training new doctors for our society. That is what this does."
Let's be clear: The $80 million for the GME expansion doesn't come close to covering the massive loss in federal funding that the Medicaid expansion would have brought to Florida. Beyond the issue of improving access to care, hospitals and the healthcare sector are among the biggest economic drivers in any community and the loss of this much money will most certainly hurt the larger state economy. It makes no sense economically because it was a political decision.
But at this point, Florida residents who support funding for healthcare have to take the good news where we can get it, and in increments of any size.
Problems with electronic health records systems and the overall burden of rules and regulations imposed by payers and other entities are having a deleterious effect on the professional satisfaction of medical doctors, survey results find.
Physicians are most satisfied when they deliver high quality care to their patients, but problems with electronic medical records and red tape are hindering their practices, a multi-state survey shows.
The RAND Corp. report was commissioned by the American Medical Association and surveyed hundreds of physicians in six states to identify the factors that influence professional satisfaction. The survey found that only 20% of physicians said they want to return to paper medical records.
Most physicians, however, expressed deep frustration with costly and overly complicated EHRs that have fallen far short of their promise to improve practice efficiency.
"This is a vexing problem," Mark Friedberg, MD, the study's lead author at RAND, said Tuesday at an AMA teleconference.
"Physicians like some aspects of their EHR and the vast majority prefer EHR to paper. However, physicians also report that EHRs are not nearly as good as they can and should be. The priority, our study suggests, is to rapidly improve EHR usability and functionality."
Friedberg says the survey findings also suggest that dissatisfied physicians "could be seen as canaries in the coal mine for quality as an early indicator of potential problems with quality in the healthcare system."
"Most prior studies have conceptualized physician professional satisfaction as mattering because it may lead downstream to higher quality and better experiences for patients and patient care," he says. "Our findings at least suggest an alternative reason to really care about physician professional satisfaction by reversing the causal and thinking of professional satisfaction as actually an indicator of quality of care rather than something that is necessary for quality of care to occur."
AMA President Ardis Dee Hoven, MD, says the survey suggests that physician satisfaction is a "wind vane that shows us the factors out there that can be barriers to first-rate medical care."
"The measurement that we are using on satisfaction really reflects what is happening at the site of care and when you have satisfied doctors in working environments, you also have satisfied patients with good health outcomes," she says.
Hoven says it is understandable why most physicians don't want to return to paper records even though they complain about EHR. "It gives me better data at my fingertips in a more timely fashion to manage that patient's care appropriately. That is why we like electronic medical records," she says.
"At the end of the day the electronic medical record is what we need. At the same time it has to be usable and more intuitive; it has to be interoperable; it has to make my work flow easier, not more complicated."
Friedberg rejected suggestions that physicians are simply experiencing "growing pains" as they adapt to EHRs. "I am not sure that fairly reflects the findings of our study and the period of pain both for physicians and for patients may actually be long and something that might deserve a much more serious look," he says. "Certainly it might require quite a bit of explicit effort to address rather than waiting for it to resolve itself on its own."
The survey asked if physician satisfaction improved in practices that had more experience with EHRs.
"We found no relationship there," Friedberg says. "That to us suggests that the opposite may be true, that these issues with EHR are not necessarily an issue of physician familiarity or practice familiarity with the EHR. It really is a fundamental potential issue of the interaction between the state of EHR technology currently and the state of medical practice."
Hoven agreed that "familiarity with EHR isn't really the issue."
"Clearly usability issues, interoperability issues, workflow issues, standards that aren't practice or specialty specific, limitations on what is actually available and in many situations practices have had to actually rip out and replace systems because they simply were not working," she said. "So we still have some huge hurdles to go here to get EHR to where it really works for the physician practice in providing the care that the patient."
Jay Crosson, MD, AMA's group vice president for professional satisfaction, care delivery and payment, says "‘growing pains' may be an apt analogy but not with respect to physicians."
"In fact what we may be dealing with here is growing pains for the vendors themselves and the nature of the software. I know in my own personal experience as a physician in a medical group with an EHR that as good as they are, they need continual improvement," Crosson says. "We need to help the industry itself get through its growing pains."
Other issues affecting physician satisfaction that were identified in the survey included:
Excessive productivity quotas and limitations on the time spent with each patient. The cumulative pressures associated with workload were described as a "treadmill" and as being "relentless," sentiments especially common among primary care physicians.
Perceptions of collegiality, fairness, and respect. Within the practices studied, frequent meetings with other doctors and other health professionals fostered greater collegiality and satisfaction.
Red tape mandates by government and payers also played a role in chilling physician satisfaction, although no single source was blamed. "What physicians did express was the overall burden of rules and regulations from a large number of sources not limited to the government at all and including also those that were imposed by payers and other entities in the healthcare system," Friedberg said.
"It was more of a sense of overload than any one or two specific sources of these rules and regulations."
Training young cancer patients and their families basic methods of preventing central line-associated bloodstream infections could have implications beyond pediatric oncology, since healthcare is increasingly delivered in outpatient settings.
Training pediatric patients and their parents in basic infection-prevention protocols such as hand hygiene, the use of gloves and masks, and proper tube and needle replacement dramatically lowered bloodstream infections for children with central lines receiving outpatient chemotherapy.
A study published this week in Pediatrics by researchers at The Children's Hospital at Montefiore (CHAM) found that the protocols reduce Central Line-Associated Bloodstream Infection (CLABSIs) by 48% and bacteria in the blood by 54%.
The study's author, Michael L. Rinke, MD, says the findings could have implications beyond pediatric oncology because more healthcare is delivered in outpatient settings.
"Our goal is that this starts in ambulatory pediatric oncology patients, but spreads to other kids using central lines, and then spreads to adults with central lines, and then spreads to anyone dealing with a medical device at home," says Rinke, assistant medical director of pediatric quality at CHAM.
"All of those devices confer risk and if we take the time to do really great education with clinicians, patients and their families and involve them in the process and show them the process toward keeping things as safe as possible we can have really big wins in terms of patient lives and medical dollars."
Rinke says earlier research has shown that children receiving outpatient chemotherapy develop three times as many bloodstream infections from their central lines than do children in hospitals. In addition to the serious and potentially fatal health risks that come with bloodstream infections, they can cost up to $45,000 for additional treatment.
The CHAM study used a multidisciplinary team led by nurses who worked with Rinke to educate clinic nurses, homecare nurses and patient families on how to safely and reliably manage central lines. Infection rates of 330 patients who received the intervention were compared to 339 patients who received ambulatory care before the intervention started.
Assessments were completed pre- and post-intervention to compare CLABSI rates and positive blood culture rates. Rinke says the intervention may have prevented more than 70 hospital admissions for children with cancer and saved hundreds of thousands of dollars in additional healthcare costs.
"The goal of any pediatric oncologist is not to admit their patients," Rinke says. "These kids go through so much already and to have them in the hospital for an infection they didn't need to get is heartbreaking for everyone involved. Any time we can keep them out of the hospital that is a huge win. And it also a huge win for the medical system in terms of dollar because each of those hospitalizations cost real money for insurance companies and hospitals that don't get reimbursed for these infections all the time any more. It a real quality of life issue for the kids to say nothing of the risk for mortality and lasting morbidity."
Clinicians leading the study saw that homecare nurses and families received additional training in hand hygiene, tube changing and the use of needles, gloves, masks and dressings. Teams held regular meetings, webinars, and learning sessions to discuss quality improvement practices and to identify lessons learned from every infection.
Families also received education on central line safety, were asked to monitor provider compliance and regularly were asked to demonstrate their own abilities to care for their child's central line.
Rinke says the common-sense protocols are easy to implement, but can prove challenging to maintain. "It's the same thing when people floss when they're about to go to the dentist," he says. "We need to be reminded, but more importantly we need to have systems in place to make sure everybody does the right thing every time."
Rinke says the critical component to reducing infections was letting front-line nurses and patients' families lead the way.
"If I was the one leading this project it never would have gone anywhere. It was getting nurses involved, getting homecare nurses involved, and getting patients and their families involved that drove this project. You have to empower them," he says.
"I told them: 'We need your help. Tell us the best way to do this. If you see a doctor or a nurse treating your child's line in the wrong way stop them. We want you to stop them and here is a respectful way to do that. Here is a script on how to do that to make sure your child gets the best line care possible.'"
"The important thing we can take from this in addition to what has already been said in a lot of studies about improving central line infections is that you can do it in the ambulatory setting, outside the controlled inpatient doctor-and-nurse-only-taking-care-of-the-line-setting. You can get parents and patients involved and you can trust them to be advocates for better line care for their own lines and to do it well."
