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."
Medicare Part A and Part B appeals rose markedly between 2008 and 2012 with most of the increase coming from appeals of inpatient hospital claims. "We think that the recovery audit contractors are driving a lot of the increase," says an OIG official.
First-level appeals for Medicare Part A and Part B are on the rise, but most of those appeals are ultimately unsuccessful, a new federal study shows.
The study from the Office of the Inspector General for the Department of Health and Human Services found that more than 1 billion Medicare claims were processed in 2012, of which 3.7 million were appealed at the first level—an increase of 33% since 2008. These are also known as "redeterminations"
"About 80% of the first-level appeals were for Medicare Part B services and 20% for Part A," said Maria Maddaloni, team leader at OIG's Office of Evaluation and Inspections in Boston. "But Part A appeals have increased by over 500% from 2008 to 2012. Most of the increase was with appeals of inpatient hospital claims. We think that the recovery audit contractors are driving a lot of the increase."
By 2012, appeals involving RACs accounted for 39% of all appealed Part A claims. Contractors decided in favor of Part A appellants at a lower rate than that for Part B appellants.
"In 2012, only 1 out of 4 Part A appeals was decided in favor of the one making the appeal," Maddaloni said. "In 2012, about half of Part B appeals were decided in favor of appellants. This was also the case for appeals of physician services, which make up most of the Part B appeals."
Maddaloni said the study represents OIG's first examination of the first level appeals process for Medicare Parts A and B. The study focused on redeterminations processed from 2008-2012. The study analyzed the Centers for Medicare and Medicaid Services' Contractor Reporting of Operational and Workload Data system. OIG auditors surveyed 18 contractors that process redeterminations for Medicare Parts A and B and interviewed five RACs to learn more about how they process redeterminations.
While contractors generally met mandatory timeframes for processing redeterminations and paying appeals for successful appellants, Maddaloni said the RACs were not as prompt in meeting timeframes for transferring case files for second-level appeals. "Processing timeliness for Part A appeals dropped in 2012," she said.
"Contractors told us it was because of the increase in Recovery Audit Contractor appeals. Part A appeals typically require the review of an entire medical record, so they're much more time and resource intensive to process than Part B appeals."
Maddaloni said the audit could not provide detail on the specific claims. "Most of the Recovery Audit Contractor appeals involved short-term inpatient hospital stays. Aside from that, CMS has limited data available," she said. "However, it's implementing the Medicare Appeals System for first-level appeals. This is a database that will have specific information about appeals. It should make it easier for contractors and CMS to track appeals."
"In fact, two of the three recommendations in our report have to do with the Medicare Appeals System," she explained. "We recommended that CMS use it to oversee contractors and to monitor data quality. Our other recommendation was that CMS encourage information-sharing, like best practices, among its contractors."
Hospitals that have the best survival outcomes are not doing the best job in the area of patient satisfaction, says a healthcare economist. Better indicators of quality are the number of beds and patient volume.
While quiet hospitals with friendly doctors and nurses who are attentive and quick to answer bedside buzzers might boost patient satisfaction scores, they don't necessarily correlate with quality care.
A far more important indicator of quality outcomes is the number of beds in the hospital and patient volume, says Robert D. Lieberthal, lead author of the study appearing in Risk Management and Insurance Review.
"There is a lot of information patients can use to select a hospital," says Lieberthal, a healthcare economist and assistant professor at the Jefferson School of Population Health in Philadelphia. "However, this is usually a laundry list of indicators that may not mean much for the lay person or that they may be unaware even exists. Our method compares hospitals directly, so that a patient choosing between two or three hospitals can easily compare them and choose the highest quality facility."
Lieberthal's findings are based on a statistical methodology known as PRIDIT that was originally designed to detect automobile insurance fraud. He reconfigured the model and uses it to establish a predictable scale for hospital quality so that actuaries could map out reimbursement rates over years for programs such as Medicare and the Patient Protection Affordable Care Act.
"We took what is simply a statistical method and put in quality data and what that method told us was which hospitals were of higher or lower quality," Lieberthal says.
"Then we validated that by looking at whether the quality scores in one year predicted the outcomes in the next year. We created a score for 2010—these are the higher and lower quality hospitals—and then we validated that that was correlated with mortality in 2011. We both applied the method and validated it by saying that it could predict future outcomes."
Lieberthal's study relied on Medicare data available on Hospital Compare and other data from the American Hospital Association.
"Our method was designed to take these different types of data, hospital characteristics, process measures of care, outcome measures, and satisfaction and then from those measures, to determine the score. We didn't decide ahead of time what was important. Our statistical method told us which were the important measures and which ones were correlated with quality," he says.
"Hospitals that scored the highest or 'always' on satisfaction measures such as patients received help as soon as they wanted it or nurses or doctors communicated well, that was correlated with lower quality as measured through our method."
In other words, a patient in a large, high-volume hospital that is highly rated under Lieberthal's model might dislike the noise and bad food but will survive a life-threatening heart attack. "Based on this study the hospitals that have the best survival outcomes are not doing the best job of satisfying patients," Lieberthal says.
Lieberthal believes his method could be used by the federal government as a way to correlate the different quality measures that they collect and put them into a single quality score. "For example, right now Medicare has a model that they use to do mortality risk adjustment. The hospitals that tend to see sicker patients get an adjustment for that and the mortality scores that are reported in Hospital Compare," he says. "We would definitely see a value in Medicare applying this model to all of the data they generate, not just the data they put in Hospital Compare but in their much larger set of claims and other data that they generate as a large health insurer."
The study was funded by the Society of Actuaries.
"I was commissioned by them to develop a way to predict the quality of hospitals so that insurance companies and hospitals could plan their reimbursement rates," Lieberthal says.
"We see an implication of this study using the overall scores that we developed to pay more for the hospitals that were better or include the hospitals that were better in preferred provider networks. For the hospitals that didn't do as well, and some of that was because of these satisfaction measures, insurance companies might want to consider not including them in a preferred provider network."
Unlike physicians and RNs, nurse practitioners report remarkably high levels of job satisfaction thanks to a rise in opportunities to practice independently, and confidence that their earning power will increase.
A small survey gauging job satisfaction among nurse practitioners [PDF] found that 100% of them are upbeat about their profession. The survey also found that 99% of NPs are optimistic about their future, 97% would recommend becoming an NP to their children, and 96% are optimistic about the future of their profession.
The survey sample was limited and included responses from 222 NPs who attended the June annual meeting of the American Association of Nurse Practitioners in Las Vegas. Phillip Miller, vice president of communications at Irving, TX-based healthcare recruiters Merritt Hawkins and Staff Care says there are about 155,000 nurse practitioners in the United States and he conceded that only limited observations could be drawn from such a small sampling.
"It is not a scientific survey but it is more of a weathervane indicator of where things are going," Miller says. "The reason we think it is somewhat significant is that the response to the questions was overwhelming. Literally all 222 said they felt positive about it, even if it is not that great to that extent we think it is an indicator that they are pretty happy in their profession."
"And unlike physicians and even nurses we have surveyed we have never seen satisfaction rates as high. We usually get 10%–15% of the people who have something to grumble about or something that didn't meet their expectations or who have regrets. We got almost none of that this time."
High Pay and Emotional Rewards
Miller says NPs have a lot to be upbeat about.
"They are feeling pretty heady about where the scope of practice for NPs is heading. It is broadening," he says. "They are getting more autonomy. More states are allowing NPs to practice independently. There is a sense of confidence that their income and prestige are going to increase."
When asked what they plan to do in the next three years, 63% of NPs said they will continue in their practice. However, 10% said they would work independently, 10% said they would work in temporary practice, and 12% said they would work part-time.
The NPs reported seeing an average of 17 patients per day and earned an average of $95,800 a year. Miller says it is not uncommon for NPs to command six-figure salaries. "It's a good return on investment on your time and money and education for what you get," he says. "They also get the emotional rewards of taking care of patients."
The results of the NP survey provide a sharp contrast to surveys gauging job satisfaction among physicians. A recent national survey of physicians conducted by Merritt Hawkins found that 32% of respondents said they feel positively about their profession, 13% said they are optimistic about the future of medicine, and 42% would recommend medicine as a career to their children or other young people.
Shifting Roles
"NPs and doctors are a mirror image of each other," Miller says. "The things that NPs are happy about, increasing income and clinical autonomy and the feeling of more power within the system, most doctors are experiencing exactly the opposite. Doctors feel like their clinical autonomy is being eroded and that reimbursements are being cut, and in a lot of cases they are. Before they were preeminent on the healthcare team and now it's more like they are part of the team and not the dominant player."
Miller says other surveys have found dissatisfaction among registered nurses. "They're dealing with a lack of autonomy. Everyone is breathing down their necks. They have a physically more demanding job than an NP, who is pretty much interacting with patients and nurses are doing physical things such as lifting the patients and running from bed to bed in a hospital. They actually complain a lot about their bodies just not holding up," he says.
"Nurse income is not that bad but it is not as good as what you're getting as an NP. They don't have that satisfaction and they are not really feeling like they are managing the patient's care like an NP would but they are doing sort of the grunt work."
Overextended
While much has been said about NPs and physicians' assistants alleviating the physician shortage, the survey shows that 75% of NPs said there is a national shortage of NPs. More than 80% of NPs said they are overworked in their practices or are at full capacity. NPs said they spend an average of 25% of their time on non-clinical paperwork.
"We have this hope that NPs and PAs are going to ride to the rescue in the doctor shortage but we are already seeing evidence that NPs and PAs are already overextended," Miller says.
While the future looks rosy, when 100% of the responses are positive there is no place to go but down.
"The only negative I see is be careful what you wish for," Miller says. "When you become an independent practitioner the onus of running a practice and having the responsibility falls on you and a lot of doctors find that to be a challenge. That is the only caveat I see there out there right now."
The survey was conducted by Staff Care, a temporary physician and NP staffing firm and an affiliate with Merritt Hawkins under AMN Healthcare.
A small Illinois hospital comes up with a remarkably simple, inexpensive, and effective strategy to guard against falls and wins an award in the process.
By some estimates falls among older Americans cost about $30 billion in direct medical costs each year. That number may reach $55 billion in inflation-adjusted dollars by 2020 as the demographic ages and becomes more susceptible to falls.
Falls aren't cheap. Medicare estimates from 2002 placed the average cost per fall for "community-dwelling seniors" at between $9,113 and $13,507, making fall-related injuries one of the 20 most expensive medical conditions among that demographic.
The Agency for Healthcare Quality and Research estimates that in the U.S. between 700,000 and one million peoplefall within hospitals, resulting in fractures, lacerations, or internal bleeding and driving up costs. Citing research showing that about one-third of falls can be prevented, the Centers for Medicare & Medicaid Services in 2008 stopped reimbursing hospitals for treating certain traumatic injuries that occur because of falls.
With so much at stake, many hospitals have made fall prevention a high priority over the last few years. Staff at Advocate Eureka Hospital, a 25-bed critical access hospital in Eureka, Ill., recognized they had a problem several years ago and created a program to examine hospital culture and preventive strategies around patient falls.
It's worked.
In 2009 the hospital had 15 patient falls. In 2011 it had 10 falls. In 2012 they had five falls. So far in 2013, the hospital has had just one patient fall, and has vaulted into the 10th percentile among best performing hospitals in its peer group, based on National Database Nursing Quality Indicators.
The dramatic turnaround has not gone unnoticed. Advocate Eureka was a winner of the Illinois Hospital Association Institute for Innovations in Care and Quality's 2013 Quality Excellence Achievement Award.
"Our patients tend to be elderly; 83%–85% of our population is Medicare patients and as a critical access hospital we have swing beds which are skilled nursing beds and more equivalent to a nursing home level of care. They tend to be elderly," says Jane McCully, RN, CPHQ, case manager/quality analyst Advocate Eureka. "There already is a fairly high percent of the population that just fall anyway at home and elsewhere just because of their age. We felt an obligation to do as much as we could to prevent that and protect them while they were in the hospital."
After the 15 falls in 2009, the staff at Eureka formed an interdisciplinary team to tackle the issue. "In 2009 that had been the highest it had ever been and there were a lot of factors that play into it," McCully says. "Three of those falls were the same patient who wouldn't oblige the fall prevention guidelines so there are factors like that internally that play into those numbers being higher. But that was still too high."
The strategy the group came up with was remarkably simple, inexpensive, and effective. At its core was a concerted and sustained effort to raise fall prevention awareness around the hospital.
"We called it All Hands on Deck and actually educated everybody in the hospital, even volunteers and housekeeping staff," McCully says. "People that might not have much patient contact but might be passing by a room and see a patient out of bed with their yellow socks on and knew that was not where they needed to be and they'd go and check with the nurse and tell her that the patient needed some assistance."
Other simple tactics included posting white board notices in patients' rooms assessing their fall risks and listing precautions. "It noted if the patient was a high risk or a standard risk for a fall, what their level of need was as far as what kind of equipment they needed to transfer from, say the bed to the toilet, whether they needed a walker or how many people needed to assist," McCully says. "Those things were hardwired into the white board on the wall so all the nurse or staff member had to do was circle what the precaution was that that patient needed."
The hospital also posted a "fall calendar" on its website marking the number of consecutive says since the last fall—which stood at 258 days when McCully and I spoke this week. "This was an obvious way to show that the staff was keeping track of these things and that they are making a difference," she says.
Patients are also made aware of fall risks. "We have a fall agreement that we use with patients where it is appropriate to bring them on board with what their plan is as far as fall prevention," McCully says.
"We want them to understand that we know you may not like to call for help because you are used to being independent. But you are in a hospital. Things are not the same here as they are at home and you need to let us help you when you get up to go to the bathroom or whatever. Nurses and staff members on the floor do a good job of educating them."
The common theme in all of these tactics is to raise awareness of the risks posed by falls, and to create an environment where everyone plays a role in preventing them. The good news is that these tactics can be done with very little financial stake, and the return on investment can be huge.
"This is one area where I feel like we have had success in hard-wiring these practices so that everybody is on board with what needs to be done to keep the patient safe from a fall," McCully says. "Sometimes we have so many things in healthcare that are in front of us all the time, that it is hard to always focus on some of the stuff that maybe is the most important. That has not been the case with this. It is something that everybody has embraced and taken their own accountability for their piece of making it happen. We did so many different things that spoke to different groups of people as this played out that I think we were able to make a real change."
McCully says she is not concerned about staff losing focus or feeling like the problem no longer exists as the number of falls has plummeted.
"With this particular issue, that hardwire change is there and I don't see that that is going to go away when we focus on something else," she says. "I am not saying we aren't going to have another fall ever, of course. But I don't see that the changes we've made are going to be transient. They are hardwired."
High traffic volume contributed to consumer complaints about problems with the federal health insurance exchange and several states operating their own marketplaces reported similar problems on launch day.
Nearly three million people visited the federal government's health insurance marketplace by mid-afternoon on Tuesday, the first day of the six-month extended enrollment period, the Department of Health and Human Services announced.
However technical glitches and the high volume of traffic on HealthCare.gov generated widespread complaints from residents in the 36 states served by the federal exchange who said they could not access the site. Those complaints and accompanying media reports about opening day snafus for the central component of the Patient Protection and Affordable Care Act prompted public assurances from President Barack Obama Tuesday that the glitches would be worked out in the coming hours and days.
"Like every new law, every new product rollout, there are going to be some glitches in the signup process along the way that we will fix. I've been saying this from the start," Obama said during a Rose Garden address. "For example, we found out that there have been times this morning where the site has been running more slowly than it normally will. The reason is because more than one million people visited healthcare.gov before 7:00 in the morning."
"To put that in context, there were five times more users in the marketplace this morning than have ever been on Medicare.gov at one time. That gives you a sense of how important this is to millions of Americans around the country, and that's a good thing. And we're going to be speeding things up in the next few hours to handle all this demand that exceeds anything that we had expected."
The exchanges and other core components of the PPACA remain operational despite the government shutdown on Tuesday because they are funded through mandatory appropriations, HHS said. The president on Tuesday reaffirmed his rejection of demands by House Republicans who refuse to pass a stop-gap budget to keep the federal government open unless the administration agrees to delay by one year the implementation of the PPACA.
"I'll work with anybody who's got a serious idea to make the Affordable Care Act work better. I've said that repeatedly," Obama said. "But as long as I am president I will not give in to reckless demands by some in the Republican Party to deny affordable health insurance to millions of hardworking Americans."
In addition to the 2.8 million visits on the exchange website, HHS reported that by mid-afternoon another 81,000 people called an exchange hotline, and 60,000 requested live chats. However, HHS officials at an afternoon media teleconference repeatedly declined to tell reporters how many people had signed up for coverage, which takes effect on Jan. 1, 2014 for people who enroll before mid-December.
"We certainly appreciate the question and obviously we are interested in that information too," Julie Bataille, communications director at the Center for Medicare and Medicaid Services, told reporters. "I would just point to some historical experience getting data and what we have seen with other implementation efforts over time and we know that it takes some time to pull accurate data and information together. We will be able to do that for you as soon as we can and we will make sure to let you know what that schedule will be."
In addition to problems with the federal exchange, several states operating their own exchanges also reported problems related to high volumes and technical glitches.
CMS Administrator Marilyn Tavenner sat in on the half-hour long media call and got an earful from journalists across from across the country who related the frustrations of people trying to access the exchanges in their states. Like the president, Tavenner reminded the reporters that the glitches were to be expected given the magnitude of the undertaking.
"I would just remind you that this is day one of the process. This is a marathon, not a sprint," Tavenner said.
