Consumer Reports has nearly doubled the number of hospitals that fall under the updated hospital safety ratings that the magazine first published last August.
However, the expanded review that began with 1,159 hospitals last year and has grown to include 2,031 hospitals still shows low scores across five measures: readmissions, complications, communication, the overuse of CT scans, and infections. The data from federal and state governments cover different time ranges, depending on the specific measure.
The average score for all hospitals was 49. Consumer Reports said.
"When it comes to healthcare, average should never be good enough, and this average is clearly not even close," John Santa, MD, director of the Consumer Reports Health Ratings Center, said in prepared remarks.
Santa said it was particularly worrying to see that almost two-thirds of the nation's 258 teaching hospitals that report enough data to calculate a safety score ranked below average. "Those hospitals should set the bar higher but that is not happening," Santa said.
In the New York City area, for example, 27 of the 28 teaching hospitals in the region scored below the national average. The exception: Winthrop University Hospital in Mineola, NY. Overall, 58 of the New York City area's 70 hospitals with a safety score ranked below average.
University of Connecticut Health Center, John Dempsey Hospital had the dubious distinction of earning a score of 17, the lowest score of any teaching hospital in the nation. Officials at the Farmington, CT hospital issued a lengthy statement challenging the Consumer Reports rating.
"This is the second Consumer Reports piece on hospital safety in less than one year. However, the current report is accessing data that is still more than two years old and does not reflect the fact that the Health Center has substantially improved, across the board, in safety metrics. As such, the report does not accurately portray the quality of care available at the UConn Health Center today," the statement read.
"We urge the public to also use other sources of information that are current, such as the U.S. Department of Health and Human Service's Hospital Compare website."
"According to Hospital Compare, in categories where statewide comparisons are available, the Health Center is above the Connecticut average in the majority of quality metrics. For example, current Hospital Compare data shows the Health Center, as compared to other local hospitals, among the best for:
Ensuring that all heart attack patients are given aspirin at discharge as well as a prescription for a statin at discharge, with scores of 100% and 99% respectively.
Assessing and providing pneumonia vaccine, with a score of 94%.
Making sure patients receive treatment at the right time to help prevent blood clots after certain types of surgery, with a score of 100%.
The hospital's rate of double CT scanning of the chest has been almost zero for the entire last year, and double-scanning of the abdomen has decreased by 62% since July of 2012."
Clinch Valley Medical Center in Richlands, VA, received a score of 14 from Consumer Reports, the lowest score in the nation. Beth Stiltner, the hospital's quality and risk manager told the magazine that its criteria for ratings represent "only a small piece of the entire hospital's performance." The hospital's Website notes that it was recognized this year by Virginia Hospital & Healthcare Association for improving patient safety.
Santa conceded that the Consumer Reports ratings have their limits.
"Our Ratings are an important measure, but they're not the only source you should consult. They don't, for example, assess how successful hospitals are at treating medical conditions," he said.
He encouraged patients planning a hospital stay to consult multiple sources, including Hospital Compare and Leapfrog Group.
In June, the Gingham Tree Resale Shop will celebrate its 40th anniversary as a major fundraiser for Advocate Good Samaritan Hospital in the Chicago suburb of Downers Grove, IL.
In fact, the shop is two years older than the hospital it supports. In the past 10 years Gingham Tree, located on the southeast corner of the hospital campus, has raised more than $2.1 million to support projects at the hospital that include upgrades to the Level 1 trauma emergency department and the pediatrics unit, a renovation of the cardiac catheterization lab, and new operating equipment for the surgical suites.
The shop, which is owned and operated by the hospital auxiliary, was one of four programs to receive the American Hospital Association's 2013 Hospital Award for Volunteer Excellence (HAVE) for "extraordinary efforts of volunteer programs and the positive impact their contributions have on the patients, hospitals, health systems and communities they serve."
"We sell everything. Our motto is 'You give us good stuff. We do great things,'" says Ausra Paronis, a co-supervisor of the 80 or so volunteers who work at Gingham Tree six days a week. "We go all the way from clothing to electronics to glassware, [and] dishes. Being on the property, we get a lot of associates and volunteers who will drop by. Our visitors are some of our biggest customers; our patients who are here for a test of some kind will drop by while they are waiting for the results or if their doctor is late."
Laura Neiberg, Good Samaritan's vice president, ancillary services and community health, says Gingham Tree and its volunteers "enhance our mission in a number of ways."
"Our core competency is building loyal relationships and having the shop is another way for us to build relationships with our communities, both with the opportunity for people in our community to have a place to donate things that they no longer need or want or have the ability to use. But it is also an opportunity for those in our community who may be less fortunate to have a place where they can shop reasonably."
Neiberg says the secret to the success of Gingham Tree is the volunteers. "There is a halo effect from the fact that it sits on the hospital campus," she says. "But I don't think its success is as much because it sits on the campus as it is about the volunteers who are so creative in reaching out to the community to make sure the donations are collected and to literally bring customers in."
"They market as well as any retail store. They will market to some of the senior residences in the area that might have buses where they can people around. They will create parties and events and reasons for people to come as a destination. They create fashion shows. They take the show on the road. They will bring items that have been recently donated to the shop and they may take them to some of our corporate buildings in the area that are owned by our parent company Advocate Health Care and they will set up tables and have an opportunity to show their wares. They create a trunk show and take it on the road."
Neiberg says the hospital provides an environment that keeps the 600 or so volunteers across the hospital operations engaged and which makes it clear to them that they are appreciated.
"It's not so much about the volunteer spirits as it is about the culture we create in the hospital," she says. "We view our volunteers as part of our workforce so we treat them in a similar manner to how we treat our paid workforce. When we are having some kind of a recognition ceremony for employees we make sure volunteers are included and invited. We want to create loyalty with volunteers the same way we are cognizant of creating loyalties with physicians and associates. People are volunteering. They could decide at any time that it's not worth it to them because they're not getting paid."
"It's about recognition. It's about making sure that we are creating volunteer pride as well as creating pride in the organization they are volunteering for. It is about having volunteers feel a loyalty to the organization that they would recommend the hospital to friends and family who need care, just as you would want an associate to do that. You want to make sure you are creating a personally rewarding experience for your volunteers."
All of this volunteer spirit isn't just a bunch of feel good pabulum. In addition to the money raised by Gingham Tree, Neiberg says the hospital has studied the practical effect of its volunteers across the spectrum of hospital operations and estimated that their combined hours of free service equaled that of 35 full-time employees.
With that in mind, Good Samaritan views volunteers as critical to hospital operations and, just as with paid staff, there is a strong emphasis on recruiting and retention.
"It's not just attracting the right people, but that you are able to keep the right people," Neiberg says. "The vast majority come from people out in the community looking for an organization they can be proud of and where they feel their time is going to be valued. It's a place where they would come for care or recommend it to their friends and family. They are looking for a place where they agree with the values of the organization. It is similar to what associates are looking for. The difference is these people don't get paid."
To make it work, Neiberg says successful hospitals have to build upon the relationships their volunteers.
"You want to make sure you have positive relationships between the volunteers and the coordinators and the hospital employees they are working with," she says. "You want to make sure they don't have a high level of stress. If it becomes too much of a hassle they will take their volunteer work someplace else where they feel they will have a more personally rewarding experience."
SSM Health Care and physician-owned for-profit Dean Health Systems announced jointly on Tuesday that they have signed an agreement to make Dean and its subsidiaries part of SSM.
SSM President/CEO William P. Thompson calls the deal "the next natural step in the evolution of our relationship and one that holds a lot of promise for both organizations."
The two providers have a long history of collaboration in Wisconsin with shared initiatives around value-based care and a jointly owned health plan.
"We want to take the capabilities that Dean has demonstrated in the relationships we have developed with them here in Wisconsin and transfer those through the rest of SSM," Thompson said.
"It brings together the two organizations that have been working together collaboratively for over 100 years so it doesn't really expand our footprint as much as it creates a new relationship between our two organizations."
The deal is expected to be finalized this summer, pending approval by Dean shareholders and federal and Wisconsin state regulators. Financial terms of the deal were not disclosed.
Craig Samitt, MD, president/CEO of Madison-based Dean, says the two organizations have built a national reputation for quality and that the move would create one of the most significant integrated delivery networks in the country.
"Dean and SSM have had a long successful tradition of 100 years of innovating and being one of the few organizations that pursued the value-based model long before the rest of the market moved in that direction," Samitt said.
The two companies already share an integrated delivery network that focuses population health in south central Wisconsin. Dean manages physician practices and SSM leverages geographic breadth and expertise in acute care. SSM and Dean jointly own Dean Health Plan, which covers more than 300,000 lives in the region.
"We thought if we have accomplished as much as we have as a virtually integrated system, imagine what we can do as a vertically integrated one," Samitt said. "We had discussions with SSM. We found that of all the parties we were speaking with, SSM was the best cultural strategic financial and operational fit for our system."
St. Louis-based SSM is one of the nation's largest Catholic health systems with more than 7,000 physicians and 25,800 employees operating in Wisconsin, Oklahoma, Illinois and Missouri. Dean's multispecialty system includes more than 500 physicians operating within a network of more than 60 clinics, the Davis Duehr Dean eye care, and Dean Pharmacy.
"By having an integrated system, we have concentrated on better care at a lower cost long before the Affordable Care Act was passed and accountable care came into vogue," Samitt said.
"We've made many innovations in our system really aimed at proving that a single organization can be highest in quality and lowest in cost at the same time. Our results demonstrate our success, ranging from Dean's status from the Wisconsin collaborative for healthcare quality. We are second in the state in a very high quality state; likewise SSM Wisconsin hospitals in their own quality measurement portfolios and as well in costs. As one of [the Centers for Medicare & Medicaid Services] ACOs… our average total cost of care is nearly 25% lower than the national average of ACOs. We see that as one of the best possible definitions of better care at a lower cost."
Adam C. Powell, a healthcare economist and president of Boston-based consultants Payer+Provider Syndicate, says news of the merger is not surprising.
"SSM Health Care and Dean Health Systems are not strangers, and have been discussing a merger for over a year," Powell wrote in an email exchange. "Dean and SSM have been partners for a century and have existing ties. SSM Health Care already owns about half of Dean Health Plan and a small stake in Dean Health Systems."
"What makes this deal interesting is that it appears to also be a for-profit to non-profit conversion. Dean will go from being a physician-owned for-profit to a subsidiary of a non-profit. Furthermore, SSM is Catholic, while Dean is not. As we have seen a recent wave of de-Catholization and for-profitization, this is a noteworthy counterexample," Powell said.
"Given the broader geographic scope of SSM Health Care, this merger should enable SSM to widely employ Dean's competencies at physician practice management. Many hospital systems are forming tighter linkages with physician practices in order to be able to more effectively manage costs and deliver high-value care," he said.
"This merger has the potential to give SSM Health Care greater ability to acquire and manage physician practices both in Wisconsin and throughout the Midwest."
In our annual Industry Survey, a majority of healthcare leaders cited organized labor a threat, placing it among their organization's top three concerns.
What is the nature of that threat and what is the best way for leaders to address this?
Wright Lassiter III
CEO
Alameda County Medical Center
Oakland, Calif.
On Creating a Dialogue: Almost 90% of our employees are represented by unions. When I arrived at ACMC it was contentious largely because there wasn't good communication. In the organization oftentimes you've had a lot of financial strife, and leadership turnover doesn't allow leadership to sit down with unions and develop a partnership. So in our case we have pretty positive relationships with the majority of our labor unions and they understand that the purpose of the partnership isn't for them to threaten us or force us to do things that aren't economically viable or to be a barrier to creating a culture of excellence. They are really there to partner.
You walk around our organization now and look at the boards for labor unions and you will see things like "Working on a partnership to be an employer of choice" instead of things like "Management is evil" or "Down with Wright Lassiter!"
On Building a Relationship: In the past they weren't always sure that some of the stories were as dire as they actually were. We used the phrase, "We are going to open the kimono and you guys can look at what you want to look at." And we are going to include union leadership on committees to fix things. We had conversations about things that weren't comfortable for either party at times, but I really believe it was a large part about the sincerity and transparency and open dialogue and not being afraid to say "impasse." Let's just stop bickering over this thing because we aren't going to resolve it, so this is how we are going to approach it with a little bit of give-and-take without giving the farm away
John Haupert
President and CEO
Grady Health System
Atlanta
Reduced reimbursements, healthcare reform, and the future role of safety-net hospitals rank way higher for us than do issues related to organized labor. Southern states are big into right to work and are not very organized labor-friendly. I prefer that. It's not that I am anti-union but I don't want to work in an environment where I have to go through a representative to interact with employees who are providing care to the patients. That isn't good for patient care or safety or workforce relationships and I personally prefer not to work in that environment.
The best defense is a good offense. We all as employers—regardless of if it is healthcare or any other industry—have a huge obligation to work to create a highly engaged and committed workforce. If you go through the effort of doing that it creates a much better organization. You fend off the desire of employees to reach out to unions. In organizations where senior leaders don't pay attention to what the front line is telling them about working conditions and the quality of frontline and midlevel leaders, benefits, pay, if you turn a deaf ear to that, you really open up the window for employees to engage unions in a discussion.
No. 1 is making sure you hear the voice of the employee.
Britt Berrett, PhD, FACHE
President
Texas Health Presbyterian Hospital–Dallas
The threat is probably regional in nature. Unions are very limited in the entire state of Texas but I was very familiar with unions when I was a CEO in the Sharp HealthCare system in San Diego. I'm always concerned when there is a need for a third-party intermediary, such as a union, to represent the interests of members of your team. To have a third-party voice for those professionals seems unseemly.
There is a strong interest by unions to penetrate healthcare because it is filled with professionals who have not been unionized in the past. Healthcare is almost a $3 trillion industry and healthcare professionals have an ability to move from one organization to another almost seamlessly.
Also healthcare is in a constant state of change. Unions represent more static industries. We are nimble. The nurse requirements of today will be significantly different in 36 months from today. To demand static conditions of employment is unreasonable.
One of our key performance indicators is based on our ability to retain top performers. We measure that every month by department. Yesterday I had a lengthy conversation on why one of the clerical staff left. Yes, really. We are all interdependent and if we have clerical staff who don't feel engaged, I have to know.
Joseph Pepe, MD
President and CEO
Catholic Medical Center
Manchester, N.H.
It's a top threat but I wouldn't put it in the Top 3. Most of the time you can't see this threat. But I tell my senior staff to rest assured that it is always there, hiding in the shadows and ready to pounce if the timing is right. It's best to be proactive and do what's right for employees all the time and not just when the threat comes out of the shadows.
The most important key is open and frequent communication. I have open forums with employees every month. I meet with representatives of the various departments every other month and I meet with the physicians' cabinet every month. It is important in these meetings to make them feel safe to ask questions and I encourage them to do so.
Respect is another key. This starts at the top with the CEO and senior leaders treating everyone with respect. I expect them to respect not only their supervisors and patients but also to respect each other. This is a place that is opposite from a toxic environment.
It's important to be visible. I round on the floors once a week and I encourage my senior staff to do the same. When there is a crisis, I go there either right away or shortly after that to show my support and ask if everyone is okay. Just being visible shows that you care.
Healthcare consumers who are unaware of the varying costs of routine medical tests may take solace in knowing that many physicians don't either.
"Doctors have been shielded from costs for generations," says Leonard S. Feldman, MD, an assistant professor of medicine at the Johns Hopkins University School of Medicine.
"As these systems were developing people thought it was inappropriate to expose the physicians to while they were making decisions about care. Most physicians have no idea what the costs are for whatever they're prescribing. We have never really certainly competed with one another on a regular basis based on price."
Feldman says hospitals keep patients and doctors in the dark on the cost of medical services, which contributes to the soaring cost of healthcare in the United States. With those costs poised to consume about 20% of the national economy, Feldman doctors will have to become more cost savvy.
"At this juncture in society and the world we live in, we can't afford that luxury anymore of taking into consideration these important issues," he says.
Feldman is the lead author of a new online study published this week in JAMA Internal Medicine that found that when doctors are told the price of some diagnostic laboratory test as the tests are ordered, they respond like informed consumers and either order fewer tests or shop around for cheaper alternatives.
"One of the best ways to make sure we are doing the best by our patients is to order the tests that actually needs to be ordered for that patient and to remember that there is a cost to every test that we order," Feldman says.
The Johns Hopkins study identified 62 diagnostic blood tests frequently ordered for patients at The Johns Hopkins Hospital. Researchers divided the tests into two groups and made sure prices were attached to one group from November 2009 to May 2010 at the time doctors ordered the lab tests.
They left out the pricing information for the other group over the same time period. When the researchers compared ordering rates to a six-month period a year earlier when no costs were displayed, they found a nearly 9% reduction in tests when the cost was revealed as well as a 6% increase in tests when no price was given. The net charge reduction was more than $400,000 over six months.
Researchers were surprised to find that the biggest savings came when doctors changed ordering patterns for basic and relatively inexpensive tests that are ordered thousands of times, rather than from costlier tests.
"We thought if we were able to decrease these expensive tests we will make a difference," Feldman says. "It turns out that those expensive tests aren't ordered often enough that decreasing the number ordered by a good percentage… doesn't actually save money."
"Our ABO Blood Typing test was ordered 23,000 times in six months. The complete blood count was ordered 76,000 times," Feldman says. "They dwarf how many times these expensive tests are ordered by many, many orders of magnitude."
For example, once physicians were made aware that the price of a basic metabolic panel was about $3.08 cheaper per test than the $15.44 comprehensive metabolic panel, they began to order the cheaper tests and saved more than $27,000 over six months.
It's not just about saving money, Feldman says, noting that using more discretion when ordering tests can improve quality of care.
"There is not only a monetary cost. There are downstream costs when we order tests without a specific reason that can make the ordering of that test extremely costly," he says.
"If you order testing and for some reason it turned out to be abnormal when you didn't think it would that often leads to another test and another test and another test that may in no way benefit the patient. We need to keep all of this in mind when we are ordering tests. We have a responsibility to provide the high-value cost conscious care that this country needs to afford its healthcare system."
Feldman concedes that there will be times when ordering several diagnostic blood tests at the same time is appropriate, even if some of the tests are later shown to be unnecessary, because it's less expensive to get a quicker diagnosis than it is to have patients run up hospital bills while waiting for answers.
Feldman says he believes that the cost savings found in his study could be replicated at other hospitals.
"If I were a CEO that had a provider order entry system that allowed me to easily show these costs I would certainly start showing the cost of a lot of our relatively inexpensive but frequently ordered tests. You are better off if you are reminded of it right when you need it. That was part of the power," he says.
"There are lots of studies out there where people have gone on with big educational efforts and the problem is they require a lot of effort from the faculty and they are quickly forgotten if they're not brought up on a regular basis," he says. "The beauty of ours was that it was a very cost-effective way of providing this information on a continual basis."
At the same time, Feldman says physicians do not need to be aware of the cost of every test or professional service they provide.
"I am worried about people getting cost overload," he says. "But for the tests that I know that my docs are ordering every day and maybe on a repeat basis… if I had the opportunity that would be where I would try to make the biggest impact."
When merger talks collapse between two health systems both sides usually take pains to insist that the process was pleasant and the parting was amicable.
So it came as a surprise that Sanford Health would offer barbed remarks after announcing that its months-long confidential merger talks with Minneapolis-based Fairview Health Services ended with no deal in place.
"Sanford Health has a philosophical policy of 'only going where we are invited,'" CEO Kelby K. Krabbenhoft said in prepared remarks.
"It seems as though the incredibly positive beginnings to discussions of the merger of Fairview Health and Sanford Health, has turned into a situation that finds us being unwelcome by some interested parties and key stakeholders of our proposed merger partner. It is inconceivable and unacceptable to me that we would ever propose a merger without the affirmation of these parties."
Krabbenhoft's ire appeared to be directed at Minnesota Attorney General Lori Swanson, who at a public hearing she called on April 7, grilled executives from the sprawling South Dakota-based health system on the private negotiations and questioned their motives. Swanson had already detailed her concerns about the merger talks in a March 26 letter to Chuck Mooty, Fairview's interim CEO and board chairman.
"I am troubled that a small group of people, apparently composed of a portion of the Fairview Board of Directors and representatives of an out-of-state entity, would conduct private discussions without the benefit of the public's input regarding a matter of such sweeping consequences…" Swanson said in the letter.
Krabbenhoft in his remarks characterized the proposal as not some out-of-state takeover but, as a "merger of equals."
"It was never suggested that either party was 'acquiring or controlling' the other. Those terms were never contemplated because they would be rejected on their face as unacceptable to each of these historic, charitable, and successful organizations," he said. "Nonetheless, this misperception has been created to serve an agenda that undermines the good faith and emerging trust that is essential in any contemplated merger of this sort."
Mooty, in prepared remarks said he understood why Sanford "would choose to step back at this time, but the news comes as a disappointment."
"Our initial findings about a Fairview/Sanford partnership were positive and the Fairview Board was committed to fully understanding its potential benefit to our patients and communities," he said. "However, we respect Sanford's decision and our Board's current assessment of a Sanford partnership will stop."
Krabbenhoft said he made the decision to withdraw because he was "concerned that the good reputation of Sanford may be injured by a process that only intended the highest of ideals and integrity for what we believed to be a compelling solution to the challenges facing healthcare delivery today and in the future."
He said Sanford would come back to the negotiations only if Fairview and the University of Minnesota "have sufficiently resolved issues within their relationship and secured a positive understanding by Attorney General Swanson of their intentions and plans. Until those conditions seem resolved it appears prudent for Sanford to disengage from this effort and will do so immediately."
Mooty said in his remarks that Fairview would now concentrate on strengthening its existing partnership with the University of Minnesota. "Clearly, we need to ensure strategic alignment between us before we can advance new ideas for the future. However, we feel it is not the time to discuss any proposal that involves the University acquiring Fairview. As a result, our work to evaluate that proposal will stop."
CHI, PeaceHealth Merger Talks Fold
Catholic Health Initiatives and Peace Health have announced that their months of negotiations to form a unified integrated regional health system in the Pacific Northwest have ended with no deal in place.
The two Catholic health systems had signed a nonbinding agreement in mid-August to create the partnership but they said in a joint media release that they "were unable to develop an integrated model that would provide the desired benefits and serve the best interests of both organizations. CHI and PeaceHealth will remain actively engaged in exploring other opportunities to work together to strengthen their respective ministries in the Pacific Northwest."
"Bringing together two large health systems is a very complex and challenging process," John DiCola, CHI's senior vice president of strategy and business development said in an interview.
"It was also a very innovative model," DiCola says. "Though it was a 50-50 joint venture, the new operation would consist of 100% of PeaceHealth's organization and CHI would contribute, if you will, 20% of its organization – the hospitals in Washington and Oregon. We just could not integrate this in the way felt would provide the desired benefits and serve the best interests of both organization and our communities.
"We spend a lot of time trying to work this out. That's the purpose of the due diligence process. CHI and PeaceHealth had good discussions. We agreed on a lot of issues, but all of the pieces have to fit, not just a few of them."
"We will keep the door open, keep the dialogue going; we had good discussions and we maintain a good relationship and have a lot of respect for each other."
Peter Adler, chief strategy officer at PeaceHealth, declined to provide specifics on where the breakdowns occurred in the negotiations, but he said the two health systems ended the talks amicably and by mutual agreement.
Radiologists are complaining that their specialty has been the target of too many sticks and not enough carrots as the federal government looks for ways to control cost growth in Medicare.
The latest skirmish is pitched around the Centers for Medicare & Medicaid Services' 25% multiple procedure payment reduction to Medicare reimbursements for interpretations of advanced diagnostic imaging scans performed on the same patient in the same session. The rule, which took effect in January, applies across all physicians in a practice.
Geraldine McGinty, MD, chair of the American College of Radiology Commission on Economics, is the co-author of a study that she says refutes the government's assumptions that significant efficiencies in physician interpretation and diagnosis are gained when different providers interpret different medical imaging scans performed on the same patient.
"Medicare believes there are efficiencies so that when a subsequent service is performed, that the physician that is furnishing that subsequent service does not have to make the same effort they would have to make if there were no other services performed in the same session," McGinty says. "We don't believe that that is true and our paper clearly shows that it is not."
The rule does not affect the number of scans ordered; only interpretation of scans already performed, and has been expanded to physical therapy, cardiovascular, and ophthalmology technical services as well.
McGinty's study found no intra-service work duplication when different exam interpretations were offered by different physicians in the same group practice. She says small potential efficiencies were found regarding pre- and post-service activities.
Across all scan types this corresponds to a maximum Medicare professional component physician fee reduction of only .95% – 1.87% for the same type of scan. For services from different scan types duplications were too small to quantify, McGinty's study found.
"In a practice like mine… the patient who sustains a head injury and a pelvic injury, if they had a CT scan, that would be read by the neuro-radiologist. And if they had a pelvic fracture, that would be read by a body imager or a musculoskeletal radiologist," McGinty.
"Other than the context that both physicians knowing that the patient had come from a trauma, there is no overlap in terms of what the physicians have to do. There is nothing that makes it easier for that doctor reading that complex pelvic CT… to know that a head CT was done."
McGinty says the ACR is asking CMS to rescind the rule.
"CMS said if they were given additional data to help them understand why there weren't efficiencies across the group practices they would consider it," she says. "We met with CMS on Monday and the paper was out just in time to share it with them. They agreed that they would read it carefully and consider it."
McGinty says ACR believes it's more effective to target reductions in inappropriate imaging by "helping physicians understand what test is appropriate for the clinical set of circumstances they're seeing with the patient."
"Sometimes that will be less imaging but sometimes it will be more imaging," she says. "More often it will be doing the right imaging first, as opposed to doing a test and realizing it didn't get you what you wanted, whereas if you had had the support of a radiologist and the appropriateness criteria that we developed with the ACR, you would have done the right test first."
Even with the reduced reimbursements, McGinty says physicians will continue to offer their interpretations of imaging because they put their patients' health first and foremost.
"We are doctors. I would find it hard to believe that somebody would not do an additional study because of these cuts," she says. "But again there are a lot of stresses on outpatient practices and people are trying their best to provide high quality care and invest in new technology and give jobs to their staff and balance all those things."
It is not clear what costs savings will be generated by these latest reimbursement cuts, but McGinty says this is part of larger and troubling trend to target imaging services.
"It's important to understand that radiology has been subjected to something like 12 cuts since 2006. This is just one additional cut on top of many cuts, so practices are really hurting," she says. "We are looking for incentives to provide higher quality care but there have been a lot of sticks and very few carrots for radiology."
With all of the challenges facing healthcare providers under the Affordable Care Act, it's sometimes easy to forget that progress is being made on common sense care coordination strategies.
This is not to say that there aren't legitimate questions about the efficacy of "ObamaCare" or other healthcare reforms that are designed to slow healthcare cost growth, all of which will be debated for years to come.
However, across the country we are seeing a growing movement toward strategies that identify community resources and pull them together to improve population health.
Rick Foster, MD, senior vice president of quality and patient safety at the South Carolina Hospital Association, spoke with me recently about the Palmetto State's efforts to reduce readmissions and emergency room visits by improving care coordination. "We are trying to look at all the different organizations involved in care transition work," Foster says.
Some of the state's projects are in line with Center for Medicare & Medicaid Innovation care demonstration projects, including an initiative in the Spartanburg region that starts this month and that will send home health coaches into the homes of chronic care patients within 72 hours of discharge.
"Our hospitals realize that we are moving [toward] value-based reimbursements. We have been working for a number of years in a collaborative environment on how to move toward improving quality and safety and also better coordinating care. That challenging transition from volume-based to value-based won't happen overnight. You can't just flick a switch."
Instead, Foster expects to see more and more partnerships developing between hospitals and other health and healthcare organizations to improve community health, particularly for people with chronic or complex illnesses.
"Hospitals are going to be major partners in the community to improve community health," he says. "How do they work with other providers, physicians, home health and nursing homes and the community in general to reach out and keep the patients out of the hospital? This is very much new territory; the value-based approach that asks 'what are we doing for the community' and also tries to focus on those patients who do need the hospitals."
South Carolina's hospitals have been willing to work with other partners, Foster says, because they realize they can't do it alone.
"They have to work with home health agencies and long-term care facilities and primary care physicians. We also have a good relationship with the state office on aging and there are area offices where they can tap into services like Meals On Wheels that traditionally were seen as somewhat separate from the healthcare system. Now we're realizing that they are all interrelated if you are going to effectively manage chronic illnesses outside of the hospital."
Foster says it's critical to leverage the existing resources that will vary from community to community.
"Maybe the same volunteers doing Meals On Wheels we could provide some basic training on how to be a home health coach and at least provide basic assessments of patient needs," he says. "Then you may have a second level where you have some folks with clinical training. We are doing a pilot in one rural community here around community para-medicine. We take paramedics when they're not on calls to clinical evaluations or withdraw blood for evaluations. They can go to the homes of the highest risk patients."
"We have some communities where retirees are being trained to be community health workers. We have some communities working with a university or a college and they are getting students to do this. It's a matter of looking at the resources in the community, what already exists, and how to connect them in a more efficient way. Until now they've been kind of in their own silos."
These home health visits will allow providers to evaluate and address living space issues for patients that would go unnoticed inside the hospital walls."
"There will be patients with high readmissions rates that just have a very poor environment as far as they don't have a good social infrastructure with family members or access to transportation. Those are the ones where having the Meals On Wheels and having someone come into their home to check on them is important."
How will we know if these coordinating efforts are working?
"Probably the biggest measure at least in the early stages is going to be readmission rates and preventable emergency room visits," Foster says. "That is the way you identify these patients before they have two, three, four, five readmissions, is that initial admission or the ones who are coming in frequently to the ER."
When asked what healthcare delivery in South Carolina might look like in 10 years from now, Foster envisions regional integrated community health systems and health improvement networks that include hospitals, patient-centered medical homes, and primary care practices that are connected with other human services.
"They won't have to be owned by one entity. You would have some coordinating structure a core group but you pull together all the key resources and have a community-based health improvement network that is looking at the needs of various populations," he says. "Right now this is focused on the resources that will help people manage their own health."
Hospital Corporation of America announced this week that it has formed an alliance with a Dallas-based freestanding emergency room system.
HCA North Texas Division's "Hospital and Emergency Care Alliance" with First Choice Emergency Room was touted in a joint media release by the two for-profit companies as a way "to improve patient continuity of care through multiple access points for emergency services within the Dallas/Ft. Worth area… from First Choice ER to HCA's area facilities, as well as create a joint quality assurance process and team."
The two companies have formed a "Joint Quality Assurance" team to support coordinated transfers of patients between facilities.
The agreement aims to ensure bed availability for First Choice ER patients needing acute care services provided by nearby HCA hospitals. First Choice ER transferring patients will avoid HCA hospitals' emergency departments and will instead be directly admitted when non-emergent criteria are met.
Thomas S. Hall, president/CEO of First Choice, said in prepared remarks that "this exclusive collaboration gives our patients direct access to HCA's 5,000 physicians and 11 local hospitals" in the North Texas region.
Adam Powell, a healthcare economist and President of Boston-based Payer+Provider Syndicate Today, said in an interview that the alliance makes sense for both companies.
"Freestanding emergency rooms appeal to consumers because they offer potentially shorter wait times and greater convenience than traditional hospital emergency rooms. However, they lack the extensive capabilities of hospitals and need to transfer a portion of their patients," Powell says.
"One issue that they confront when doing so is a lack of availability of inpatient beds. Freestanding emergency rooms compete with emergency rooms attached to hospitals for inpatient capacity. When hospitals are overcrowded, they must divert outside admissions. This alliance provides First Choice patients peace of mind that they will have access to a decent hospital bed if they need one. Furthermore, the alliance provides HCA with a pipeline of patients in legitimate need of a hospital admission. Thus, First Choice benefits by being able to improve its perceived quality, while HCA benefits from the increased volume."
First Choice ER will have access to the HCA Transfer Center, a 24/7 call center to coordinate patient transfers. The two companies said the access will facilitate physician-to-physician conversations and communication with the admitting hospital.
Tony Kong, director, Healthcare & Life Sciences for consultants West Monroe Partners, LLC, says the alliance is part of the overall trend in healthcare for hospitals to expand patient access in anticipation of the Patient protection and Affordable Care Act.
"The anticipation is that we will have more consumers with coverage come Jan. 1, 2014, which means there has to be greater access to care. That care has to come anytime of the day, when there is a need," Kong says.
"We are seeing this across multiple geographies where hospitals either open up their own emergency room center that is more designed like an urgent care clinic or they are partnering with another organization, such as HCA and First Choice."
First Choice operates 17 facilities in Dallas/Fort Worth, Houston, Austin, and Colorado Springs. The facilities are staffed by board certified emergency physicians and registered nurses, and are equipped with advanced diagnostic equipment.
HCA North Texas Division operates 10 hospitals, one children's hospital, one psychiatric hospital, 12 ambulatory surgery centers, 13 imaging centers, and two freestanding emergency rooms in the DFW area.
Solid job growth in the healthcare sector in March continued to prop up national job creation numbers during an otherwise anemic month. Healthcare accounted for 23,400 of the 88,000 new jobs created in March, according to the U.S. Bureau of Labor Statistics.
Within the healthcare sector, 15,000 jobs were created in ambulatory services, which includes physicians' offices, and 8,000 jobs were created in hospitals.
Andrew Hanson, a research analyst at the Center on Education and the Workforce–Georgetown University, says healthcare job growth is expected to continue grow as Americans age.
"The fact that healthcare is one of four new jobs in this month's report is very much in line with our expectations," Hanson says. "Given the sort of underwhelming job growth overall, the number of healthcare jobs might be a little bit less than we might expect, but that doesn't have so much to do with its strength relative to other jobs. It's more that there is weak job growth overall in this report."
Healthcare created 62,900 new jobs in the first quarter of 2013, a pace that is significantly lower than the 88,200 jobs in the first three months of 2012. In 2012 the healthcare sector created 320,600 jobs, BLS data show.
Hanson cautions against reading too much into the dramatic drop in job growth in the first quarter of 2012 when comparing the same period in 2012.
"It's not a big deal," he says. "If you look at the trend in healthcare jobs, the number of healthcare jobs that the economy has been adding on a monthly basis beginning in 2009 is very steady. There are fluctuations from month to month, but they are subject to revision."
Slightly more than 14.5 million people worked in the healthcare sector in March, with more than 4.8 million of those jobs at hospitals and more than 6.4 million jobs in ambulatory services, which includes more than 2.4 million jobs in physicians' offices.
BLS data from February and March are preliminary. "Keep in mind these numbers are going to be subject to revision," Hanson says. "The BLS made provisions that added 75,000 from previous reports in this edition. Just because growth appears weak for a month doesn't mean it is going to be weak in the long run. You have to look more at long-run growth trends in healthcare and the overall job market."
In the larger economy, the nation's unemployment rate remained essentially unchanged at 7.6% in March. New jobs were largely clustered in the professional and business services sector (51,000), construction (18,000), and healthcare (23,400). However, retail trade shed 24,000 jobs. Within the government sector, U.S. Postal Service employment fell by 12,000 jobs.
BLS said 11.7 million people were unemployed for the March, which is a slight improvement from February's measure. The number of long-term unemployed, defined as those who have been jobless for 27 weeks or longer, was little changed at 4.6 million in March, and represented 39.6% of the unemployed.
"The report overall was underwhelming—88,000 jobs in March after 237,000 jobs in February," Hanson says. "The unemployment rate fell, but mostly for bad reasons. More people were leaving the workforce than jobs were being added. People shouldn't interpret the falling unemployment rate as a good sign. Really it's about the number of jobs we are adding each month. Sometimes people inflate the importance of these monthly numbers, and really it's more important to look at the long-run trends."
