It's spring, and the annual playoffs for the nation's professional basketball and ice hockey leagues are well underway. Millions of Americans will be latched on to their televisions in the coming weeks and months to see how the games play out.
Running along a concurrent timeframe, however, is a much smaller competition in Sioux City, Iowa with which many of us who are gravitationally challenged can more closely identify.
Bob Peebles, CEO of Mercy Medical Center-Sioux City, and Peter Thoreen, CEO of nearby St. Luke's Regional Medical Center have entered into a friendly contest to see if they can lose 10% of their body weight over three months.
The Sioux City Journal reports that the contest began on March 27 when Thoreen and Peebles weighed in at 222 pounds and 242 pounds, respectively, at a ceremony in the City Council Chambers. When the contest ends on June 27, the loser writes a $500 check to the winner's favorite charity.
If there is a tie, the CEO who has lost a higher percentage of body weight will be declared the winner. That could tip the scales in Peebles' favor.
"We are both cheap. Neither one of us is going to want to give a $500 check to the other," Peebles told The Journal. "And we're a little bit competitive as CEOs. So I am looking forward to this challenge. I'd like to set the stage in this community and how important it is to change lifestyle and be more healthy ... also setting the stage for all our associates in the entire community. We are healthcare executives. We need to set the example."
There is much to like about this contest.
We know about the problem. The Centers for Disease Control and Prevention estimates that more than 65% of Americans are overweight or obese. In Iowa, the CDC reports that one in four people is obese. The misery and cost of treating obesity-related chronic diseases such as diabetes, cardio-vascular issues, and bone and joint damage are staggering.
And it affects just about everybody everywhere. In fact, there is some evidence that overweight and obesity are more prevalent among healthcare workers than in the general public. A recent study in Journal of Nursing Administration examined survey data from 2,103 female nurses and determined that 55% of them are obese.
By putting themselves on display in a weight loss contest, Peebles and Thoreen have personalized and de-stigmatized obesity and overweight in a way that will encourage others to examine and change their own unhealthy habits.
The two CEOs are telling the world how much they weigh. Many people would be mortified to publically divulge that information about themselves. This simple act by two well-known community leaders is as disarming as it is empowering.
Acknowledging that you are overweight is the first step in addressing the problem. An honest self-assessment is often accompanied by a will to change. As the saying goes, you can't manage what you can't measure.
The weight loss strategy the CEOs have adopted provides a sensible roadmap, rather than a silly or dangerous fad diet. It took decades for them—and us—to eat our way into this predicament, and the solution won't be found in a fad diet or a temporary exercise regimen.
Anyone who has dieted will attest to the difficulty of losing weight. It is even harder, however, to keep the weight off. Even worse, it is discouraging for many people who work hard to lose weight only to see it return after they stop dieting because they haven't made any other adjustments in their lives.
Peebles and Thoreen will both use the Blue Zones diet plan, which stresses smaller portions of healthier food, exercise, and other lifestyle choices.
We will continue to follow the contest as it wends along toward the June finish. Perhaps then Peebles and Thoreen will be willing to tell us how much they've lost and how much they've gained.
Because I am a healthcare nerd, one of my favorite pastimes each day is to examine the Around The Web Sectionof our HealthLeaders Media website.
Each morning, HealthLeaders editors awaken before you do and scour the mainstream media to provide links to the compelling healthcare-related stories of the day from across the country.
Because these stories are written mostly by newspapers for the general public, reading Around The Web provides healthcare insiders with insight into what issues are on the public radar. Oftentimes, we can spot trends in healthcare and the public's perception of the industry by reading seemingly unrelated stories from different parts of the nation. Sometimes the perception is good.
More often, unfortunately, it is not.
Heavy-handed Debt Collectors
The most damaging media attention this week was leveled at Minneapolis-based Fairview Health Services, which has come under withering attack—including a front-page story in the New York Times—in the wake of a scathing report from the Minnesota Attorney General's office that raises troubling questions about aggressive and possibly illegal bill collection tactics instigated by a contractor.
In fairness to Fairview, the AG's report vented most of its spleen at Accretive Health, a Chicago-based debt collector that the health system had hired.
"Accretive's debt-collection activity is rife with violations of Minnesota and federal laws," the AG's six-volume report stated. "Accretive has hidden its true identity from patients, aggressively and illegally attempted to collect debts from patients, improperly used patient health information to collect debts, and failed to follow basic laws regarding the registration and conduct of its collectors."
The problem for Fairview, which is otherwise a highly regarded nonprofit healthcare system, is that many in the public understandably will not make a distinction between a hospital and the debt collectors they hire. It is never good publicity for a hospital when activities within its walls are described by a state's top law enforcement officer using language more commonly associated check-cashing outfits and loan-sharking operations.
Accretive already was the subject of a lawsuit by the AG's office after an employee at the debt collection company lost a laptop computer containing unencrypted personal medical records for about 23,500 at Fairview and North Memorial Health Care. Again, the public probably won't make a distinction between Accretive and the hospitals that hired it to protect their medical records.
For now, Accretive isn't saying much. The company issued a brief media statement saying that it has "a great track record of helping hospitals enhance their quality of care."
Fairview issued a statement this week saying it "decided to end our revenue cycle work with Accretive Health. This was a decision we made in the best interests of our patients and our organization."
The health system said it is committed to protecting the privacy rights of its patients and is evaluating the issues raised in the AG's report.
"We take the concerns raised by Minnesota Attorney General Lori Swanson very seriously. We have been in consultation with her on these issues for several months. We share many of her concerns and have already taken actions to address them. It is critical that our business practices align with our values and comply with applicable laws and industry standards," the statement read.
How Much Will It Cost? Depends on How Much You Can Pay.
The huge variance in hospitals charges for the same procedures is not a new story. However, it is a particularly damaging story these days because cash-strapped patients are angry and confused and looking for someone to explain why healthcare is so expensive. Also, the government is turning over every gurney to look for savings.
In this environment, reports that hospitals are charging anywhere from $1,500 to $180,000 to treat acute appendicitis will not be well received, nor should they.
"Given estimates that 60 percent of bankruptcies in the United States involve catastrophic medical expenses, these data should alarm those making decisions about our society's ability to obtain medical care without financial catastrophe," researchers wrote in a letter published online April 23 in the Archives of Internal Medicine. The report was picked up for general readership by HealthDay News and published in many mainstream media outlets, including U.S. News & World Report.
The issue of price variance is not going away. Healthcare costs are consistently outpacing inflation in the general economy. In virtually every area of commerce and services, except healthcare, consumers can get on the Internet and shop prices.
Yes, informed consumers could conclude that healthcare pricing is highly variable because healthcare is far more complex than buying a set of tires. However, it is more likely that most consumers will conclude that:
Hospitals charge as much as they can get away with charging;
Hospitals don't know what to charge, or how much their competitors charge, so they use a dartboard; or
Both. Neither of these options reflects well on hospitals.
Making Big Profits as Non-Profits
For the past few days, The Charlotte Observer and The News & Observer of Raleigh have done an in-depth and mostly unfavorable series of articles on nonprofit hospitals in North Carolina. The reports have concluded that the largely tax-exempt nonprofits do well to improve their bottom line, but provide very little in the way of charity care.
This is not the first time that the value of a nonprofit hospitals' tax exempt status has been challenged. Though the investigation is limited to the Tar Heel State, many of the findings could be applicable to nonprofit health systems and hospitals across the nation.
Once again, this should be a source of concern for hospitals at a time when consumers are angry about rising healthcare costs and politicians are looking for scapegoats.
The Public Conclusion
Using these select few media reports, it would not be far-fetched for some in the general public to conclude that hospitals are money-driven leviathans that deny care to the neediest, and that hire strong-armed private contractors to cow delinquent patients into paying for bills of wildly varying amounts that are based on murky and perhaps non-existent pricing schemes.
Of course, that is not a fair conclusion. However, it's understandable in a nation weathering prolonged economic stagnation and high unemployment, and with about 51 million people lacking health insurance.
Unfortunately, in tough times such as these, the perception can drive the reality.
The Cliff Notes version of the 279-page Medicare Trustees Report is that the program's Hospital Insurance Trust Fund will remain solvent until 2024, and that further action is needed to assure its long-term financial stability.
That sums up much of the media's reporting of the dense tome, which was released Monday afternoon. Immediately upon the report's release, politicians, think tanks, and policy wonks from across the political spectrum used the findings to bolster their arguments for their particular brand of healthcare reform.
Obama Administration officials played up the trustees' contention that the Affordable Care Act has extended Medicare's solvency by eight years.
"The Trustees Report tells us that while Medicare is stable for now, we have a lot of work ahead of us to guarantee its future," Acting CMS Administrator Marilyn Tavenner said in a media release. "The Affordable Care Act is giving CMS the ability to do this work, with tools to lower costs, fight fraud, and change incentives so that Medicare pays for coordinated, quality care and not the number of services."
The Heritage Foundation used the report to restate its case against the ACA's provider payment cuts. "Under Obamacare, seniors face a no-win situation. If the Administration's crude strategy of payment cuts is successful, reduced access to care for seniors is virtually guaranteed. If the provider cuts are reversed, the Medicare financial condition simply worsens," the conservative think tank said it a policy brief.
Despite all the posturing, John Gorman, chairman of Gorman Health Group, a Washington, DC-based consulting group, called the trustees report "a very serious document."
"What you are seeing is all the spin in an election year around such a politically charged document," he says. "Anything as politically charged as Medicare, when the politics of the deficit are driven by this program, any trustees' report is going to go off like a thunderclap in an election year in this town."
"Everybody is making hay with it," he says, "but at the end of the day, I thought this was a positive report that said at least the measures taken in the last couple of years appear to be working at least for the short term."
Gorman says the trustees held firm on the 2024 solvency date for Medicare for the second consecutive year. In 2010, the trustees knocked five years off the solvency of the trust because they were anxious about the weak economy. "So if they are holding the line on the date of insolvency you can assume the trustees feel the economy has improved and rather dramatically since their last report and that Medicare is on a stronger footing," he said.
Paul Keckley, executive director of the Deloitte Center for Health Solutions, says the underlying assumptions in the report are driven by "a level of economic recovery that is difficult to predict."
Keckley says the trustees "ratcheted back" their optimism for economic growth in the coming months and years when compared with other federal reports on the status of Medicare.
"But the trustees also didn't go off the deep end and say the world is going to end in 12 months," he says. "Realistically, you are able to make reasonable hunches 24 to 36 months out. That is about it. If you are splitting hairs between 2021 and 2023 solvency, that is a great economic exercise, a great lecture, but it will be nothing."
"So, what do you take out of this? No one doubts that in the last 24 months we have slowed spending in healthcare, but that is not permanent. In all of these projections there is an increase in spending on a per capita and aggregate basis," he says. "The second thing it says is the more that costs grow above the baseline, the shorter the solvency of Medicare."
Keckley says the statute also restricts the scope of assumptions trustees can use when making projections about Medicare's future. "They don't pick up non-traditional competitors in the system; for example, the impact of retail clinics on access to primary care. The statutes don't allow the agencies to incorporate things that we know happen in the real world," he says.
"They are not incorporating any dire events. What happens if there is another war? What happens if by some magic longevity in the Medicare population exponentially increases because we found a miracle drug for cancer or dementia?"
Keckley says that doesn't mean the trustees report is inaccurate, just limited.
"All of these models are based on lag indicators adjusted going forward. The future of healthcare can't be predicted based on lag indicators. You can't bet that historic visits, tests, and discharges are a basis for the future because that model is not sustainable."
A lot of heat is expected to be generated by the trustees' report on the campaign trail but Gorman says there won't be any meaningful Medicare initiatives until after the November elections.
Congress in 2013 will likely examine in more detail the Medicare reforms brought forward by Rep. Paul Ryan, R-WI, and Sen. Ron Wyden, D-OR, as well as further discussions of once-taboo cost saving measures such as raising the Medicare eligibility age, and means testing for wealthier beneficiaries.
"We are going to see the big reveal on where Medicare reforms' prospects lie next year in the deficit control debate," he says. "You couldn't have spoken about those things a few years ago, and now they are part of the firmament of the discussion and that is all positive."
"At the end of the day, the only thing that will extend the life of Medicare past the next decade is structural reform that deals with beneficiaries' demographics and their true needs with the program, the ability to bend the curve on chronic illnesses that contribute most to the increases in spending in Medicare every year, and there has to be use of capitation in the Medicare program if you want to have stability in the budget."
The Minnesota Nurses Association has filed a grievance against Allina Hospitals & Clinics, claiming that the Minneapolis-based health system violated its labor contract when it unilaterally instituted a color-coded uniform requirement that will go into effect on May 1.
"We didn't get the opportunity to negotiate this issue and it does fall under the terms and conditions of employment," says Bernadine Engeldorf, RN, first vice president of the 20,000-member MNA. "The union contract states that the expectation is that this will be negotiated.
"We didn't see evidence of a need to change what we're doing, and there wasn't an ability to sit down and have that dialogue," she says.
Allina spokesman David Kanihan says the 11-hospital health system has been talking about the switch to mandatory color-coded uniforms for "quite some time," and has "made a very dedicated effort to involve" staff.
"The reason we are doing it is because patients have told us they have a hard time telling who's who and what's what," Kanihan says. "A lot of people come into their rooms for various reasons during the course of a day and one of the things we are trying to get after is making sure that the patients understand what is going on and who they can ask for certain things. It just makes the hospital stay that much easier for the patient."
After months of discussions and feedback, he says, about 5,500 of the 8,500 staff who would be affected by the mandate voted to pick their colors in a December ballot. "We had good turnout, about 60%. Not everybody who was eligible to vote did, but a pretty large percentage did," he says. "We kept the union informed as we went through the process. We provided a lot of input opportunities from the nurses themselves. I would say we did not negotiate this with the union in any formal sense."
Nurses chose navy blue. "Nurses being by far the largest group under this program, they were able to choose the color they wanted," Kanihan says. "They are a much bigger voting block than, say, housekeepers."
Kanihan says the grievance filing will not delay the May 1 launch of the color-coded uniform requirement. "We announced the results earlier this year and a lot of nurses and other staff have already started this," he says. "We made the requisite color choices available to all of our people at a discount through a Website we set up. We're providing some level of subsidy to help employees buy their first few uniforms. Many have already done it. On May 1 we require it."
Jaci Krech, RN, administrative director of orthopedics and surgical services at Woodwind Health Campus, in Woodbury, Minn., says the 86-bed acute care hospital has used color-coded uniforms for the past five years. She believes staff at the nonunion hospital—part of the HealthEast Care System—have embraced color-coded uniforms because staff were involved in the process from the onset, and because they believe it improves patients' experiences.
"It is about really understanding the 'why' behind it—of knowing what is the purpose you are looking for and seeking feedback from the community," Krech says. "It's important that the key stakeholders are involved in the dialogue to identify 'is this the right path we want to go down and how do we want to engage the rest of the stakeholders in the decision making?'"
At Allina, Kanihan says employees support the new uniforms policy.
"They understand why we are doing it and they support the idea that it makes the hospital stay easier for patients and they want and support that," he says.
Engeldorf says dissent has been muzzled. "Are most nurses in favor of this? I think most nurse believe they have to do it because the employer is saying you will do this," she says. "Some nurses say it's a good idea but most nurses believe we should have had the right to negotiate the issue."
Kanihan says nurses and other staff may face disciplinary action if they show up for work on May 1 not wearing their appropriate colors. "They will be asked to change if they have the ability to go home and change or potentially they could be provided a set of scrubs of the appropriate color at the hospital," he says. "Repeated violations would kick off a disciplinary process but it is not going to be a heavy-handed thing. We will work with people to try to remove any barriers that might be in the way of them complying."
Engeldorf says many nurses are resigned to the mandate. "Are we going to have an action and people will show up to work and refuse to wear their uniforms? I doubt that will happen," she says. "But I've had nurses tell me 'I am doing this because I have to but I am waiting until the last day to do it.'"
It may seem odd that a leading proponent for water conservation in hospitals works in Washington, a state famous for its prodigious rainfall.
For more than a decade, Geoffrey W. Glass, director of Facility and Technology Services at Providence St. Peter Hospital in Olympia, has been finding ways to dramatically cut water use and waste. Through simple, economical, and incremental steps, the water conservation program has saved the 390-bed hospital at least $250,000 a year.
"We pay a penny a gallon to purchase water and to dispose of it, so we use the mantra that every gallon of water we see going down the drain is a penny of cost," Glass tells HealthLeaders Media.
"When we started this campaign we were consuming about 62,203,000 gallons of water a year in 1999. We consumed 31,188,000 gallons in 2010 gallons. That is just straight utility consumption, even though in the last decade our campus has grown about 15%."
At Providence St. Peter, Glass says, water is a precious resource both from an economic and an environmental perspective. "We are blessed to have probably the most sustainable supply of water in the United States. But we have other problems. For example all of our wastewater goes into Puget Sound, and as such it's challenging when we introduce pollutants and it's difficult to flush them out," he says. "In addition, through federal mandates the requirements to treat sewer water have generated huge costs. We have been seeing 10% to 15% rate increases for the last decade, to where our sewage costs have doubled in 10 years."
Laura Brannen, a senior environmental performance analyst with San Francisco–based engineering firm Mazzetti Nash Lipsey Burch, says more hospitals are coming to recognize the return on investment for water conservation.
"In the 1990s, there was this big focus on materials and waste reduction and having waste management plans. In the 2000s, hospitals realized we are using more energy than needed to still provide quality care, so we started focusing on energy reduction," she says. "We are anticipating that this decade is going to be around water conservation. Like waste in the '90s and energy in the last decade, hospitals are hugely inefficient."
Brannen says determining ROI for water conservation "is pretty simple."
"With fixtures, for example, determine gallons per flush or gallons per minute used in faucets or showers. A typical ROI around toilet bowls, for example, is literally how many toilet bowls, how much do they cost, and how much water will we save on a per-flush basis," she says. "Go around the hospital and look for leaks or running water. When we do a water audit, that is where we start—fix what's broken. And it's amazing what is broken."
That's where Providence St. Peter started.
"The first step is to collect data," Glass says. "Knowing where you stand is job one. You can't manage what you can't measure."
"We found and fixed major leaks. That is an important message. Every place I have been there have been leaks in irrigation systems, building mechanical systems, even plumbing fixtures that result in money going down the drain," he says.
Brennan says a "big offender" for water waste is irrigation. "Go on Google Maps in dry areas and you can see the lawn around the hospital is green like a golf course and yet everything around it is brown," she says. "Native planting—xeriscaping—and natural landscaping are the easy way to totally eliminate that water use. If you live in a desert or a dry area, you expect to see that kind of native planning. More and more people don't expect to see golf course lawns in places that are really dry."
Once water usage is determined and waste is identified, compare results with peer hospitals.
"In our case, we are part of a health system that includes 20 hospitals from Anchorage to Burbank" CA, Glass says. "That allows us to collect and share and compare information about how we consume all utilities. Several years ago we pulled that data and let everybody know where they stacked up."
Providence St. Peter and the local water utility in Olympia partnered in 2009 to replace 700 toilets, shower heads, and sink fixtures with modern low-flow alternatives. "That project cost us $192,000 and the utility paid 75% of the cost, which was $144,000. They paid us to do the work," Glass says.
The hospital installed a more efficient irrigation system for the campus grounds and moved away from plantings that required extensive irrigation. The water-cooled equipment in the air conditioning plant—the single largest user of water at most hospitals—was swapped out for air-cooled equipment. Refrigeration equipment and sterilizers were retrofitted for efficiency. The cafeteria's massive dishwasher was replaced with a newer model, and the garbage disposal was eliminated.
The garbage disposal "used a tremendous amount of water to flush food down the drain, so we went to a food collection system in lieu of that," Glass says. "We pick the food out of the waste stream before it could get chewed up and spit down the drain. We use a contained compactor. It is transported to the composter, cleaned, and returned. We have challenges for cleaning to keep that area sanitary, and at times it is not done as well as we like, but generally it's not a big problem."
Glass estimates that Providence St. Peter has spent about $500,000 on water conservation projects over the past decade, and has finagled about $1 million in rebates from the local gas, water, and electric utilities over the same period as part of the overall energy conservation plan.
"We are confident we can state that we are saving $700,000 a year as a result of all of these programs that we wouldn't have saved if we were doing business the way we were in 1998," Glass says. "At times there are dual benefits. Electrical pumping energy is reduced when you don't have as much water flow. We have an 11-story tower and we have to pump to get water to the 11th floor. When we use a fraction of the water we were using, that is less pumping energy."
Even in areas like Washington state where water is plentiful, hospitals should be concerned about water quality and their role as stewards, Brannen says. "Hospitals have a unique obligation to address the chemicals and pharmaceuticals that they are inadvertently or sloppily putting into the water," she says. "And the burden on the publicly owned treatment waterworks to take out a toxic soup of chemicals and to anticipate what those chemicals are and to provide clean water is an expensive endeavor, so the cost of water is going up."
Glass says finding the right person for the job is critical.
"If you have the person coordinating the hospital who has the talent to investigate this kind of stuff, turn them loose," he says. "Incentivize them too. In our case, a lot of our ROI, we invested back into programs that saved more. It created momentum. Sometimes leaders are quick to take all of the savings and divert them to another use, and that discourages the person who found the savings. Come up with a reward system that encourages this."
Glass believes that water conservation programs will become more popular with hospitals as operating margins narrow, the cost of water inevitably increases, and leadership sees the almost guaranteed ROI through conservation.
"If you can have a long-term perspective, this is a predictable way of reducing costs without having to take significant risk. And it is pretty dependable—the returns you can measure, versus business strategies that might depend on recruiting that world-class surgeon to your campus who might leave after a year," he says. "All hospitals are in a mode of trying to respond to healthcare reform and declining reimbursements. This has the benefit of being good for the environment and also good for finances."
This article appears in the April 2012 issue of HealthLeaders magazine.
Our annual Industry Survey shows that 8% of healthcare leaders count malpractice insurance and litigation among their organization's top three drivers of healthcare costs. And 58% of physician leaders say they have, in the past year, ordered a test or procedure for primarily defensive medicine reasons. How serious is this issue and what can healthcare leaders do about it?
Alan Fisher, MBA, FACHE
CEO, Advanced Specialty Hospitals of Toledo, OH
Defensive medicine remains a very serious issue, but our focus can't be on practicing defensive medicine. We need to be proactive in looking at what can be done from a quality standpoint first. If we practice good-quality healthcare, that should minimize the unnecessary and sentinel events.
At our hospital, we do a thorough examination of our benchmarks and look at those items that can be prevented. For example, if we have issues of back transfers, because we are a long-term acute care hospital, it begs the question: What could we have done proactively to avoid this? In the past couple of years, more specifically within the past 12 months, we have seen an increase in quality by being more proactive in our practices, resulting in a decrease in practicing defensive medicine.
We can practice defensive medicine all we want to, but if it is for the wrong reasons—and that is not to provide good outcomes for patients—then we are hurting both patients and ourselves.
Helen M. Kuroki, MD
Vice President of Medical Affairs Riddle Hospital, Main Line Health System, headquartered in Bryn Mawr, PA
As physicians and healthcare leaders, patient safety should be our primary concern when treating each and every patient. Unfortunately, we find that many physicians are forced to practice "defensive medicine" to avoid the possibility of being charged as negligent in a lawsuit. This practice comes in many forms, from ordering extra tests to performing additional procedures on patients.
While the threat of medical malpractice presents an enormous problem for physicians from the standpoint of both cost and reputation, it is often the patient who is impacted, spending time and money to undergo procedures that may not be medically necessary. As a result, the United States has spent billions of dollars in avoidable healthcare costs.
In general, I believe medical malpractice is in need of an overhaul. It is a selective and expensive process that does not allow fair representation for all cases, does not provide appropriate and timely compensation to deserving patients and families, and does not address the critical issue of physicians who are repeatedly sued for the right reasons and should no longer be permitted to practice medicine.
As healthcare leaders, change will only come if we work together and with our legislators to insist on the enactment of meaningful tort reform.
Lawrence Shombert, MD
Radiation Oncologist Peninsula Regional Medical Center, Salisbury, MD
I don't know that we order tests for defensive medicine, but whenever there is a doubt, you don't take the risk. If you really believe your risk of being sued was a whole lot less you might err on the side of clinical judgment.
With all the debate about tort reform I don't know if the answer is that simple. It is definitely a move in the right direction. But even if you changed it tomorrow, physicians are still going to have the mentality of being careful. Some doctors are extremely cautious because they want to do the right thing, rather than to just protect themselves. I don't think we do anything that is unnecessary; we just do maybe more studies than we have to in order to be sure of our clinical decisions.
You can complain all you want about unnecessary studies, but if you can't protect the physicians, you can't change it. Doctors can justify a study clinically because any good plaintiff's lawyer is going to justify it clinically. "Couldn't you have ordered that test, doctor?"
You can't come down on radiologists because all they are doing is a study that has been requested by another physician. It is not their decision to say clinically whether it is warranted or unwarranted. They bear the brunt of "You guys are overusing the machine." Nonsense! We were asked. We can't tell you what is a valid request and what is not.
Susan L. Davis RN, EdD
CEO
St. Vincent's Health services Bridgeport, CT
The breakdown: The problem of defensive medicine is very real, and I am honestly surprised that only 58% of physician leaders said they had practiced defensive medicine in the past year.
The drivers: There is so much information out there now for healthcare consumers on the Internet, and more often than not they come to physicians with a test that they believe they need to have done given the symptoms they have. It is a very real concern for physicians because while they may not believe the test is appropriate or needed, they feel compelled to order it because of the chance that they may be wrong. It may be only a 1% or 2% chance that they are wrong, but they are exposing themselves to litigation.
The solutions: The tough part is what do you do about it? Many would say that there is a tremendous need for malpractice reform. That is important, but that is not the only thing we need to do to address this issue. When you look at it on a broader scope, there are two things that come to mind: One is practicing evidence-based medicine and having the relationship with the patient that enables the physician to explain why that test is not needed or appropriate for the symptoms the patient has presented. The second solution comes with information technology: connecting all of the providers for that patient on the continuum of care so physicians see what has been done for the patient either at a hospital or by another provider. When those results are available, the physician is able to explain to the patient what the results of the test were and why duplicative testing is not necessary and in fact not good for them.
This article appears in the April 2012 issue of HealthLeaders magazine.
Eleven months after a deadly EF5 tornado gutted St. John's Regional Medical Center in Joplin, a temporary "component" hospital has opened in the southwestern Missouri town.
The opening marks the latest step in a remarkable rebuilding effort for a city that was devastated in the May 22, 2011 storm that killed 142 people and left homeless thousands of people.
The new and interim Mercy Hospital Joplin is a $100 million, 150,000-square-foot blockhouse that is storm-hardened to withstand the 200 mph winds that shattered windows, ripped off the roof, and tore through the interior of the old hospital last May. The hospital includes heavy duty shatter-resistant windows and reinforced door frames that shelter interior corridors.
The new hospital is an impressive display of "Show Me State" gumption from the storm-hardened people of Joplin. Even as wind-tossed debris was still settling last May, Mercy Hospital had already established roadside triage. They moved to a 60-bed MASH-style field hospital within a week, and then to modular buildings, and then to the component hospital last weekend.
The component hospital will be used for three years while a 327-bed permanent hospital is built on a 100-acre site about three miles from the gutted hospital. The new hospital is the centerpiece of a $950 million rebuilding effort for Joplin's crippled healthcare services infrastructure.
On Sunday, 41 patients were transferred during a heavy rain. Other than the damp, Mercy Hospital Joplin CEO/President Gary Pulsipher says the transfer went well. The move came just two days after a string of violent storms spawned dozens of tornadoes in the Midwest. Of late it seems like swaths of violent storms break out every week, so it was understandable when Pulsipher told HealthLeaders Media he is relieved that patients and staff are now safely housed in the component hospital.
"The storms that worried us Sunday morning were gone by midday. We got our patients moved quickly and without incident," Pulsipher says. "This is truly a facility that can get us through over 200 mph winds. At the old hospital the first thing you notice when you go up and look at it is all the windows are blown out. These new windows are designed around that. Plus we designed safety corridors where staff and patients will be able to go and be free from destruction [like that] of the tornado that hit us almost a year ago."
The component hospital has 55 private rooms that can be switched to semi-private if needed. It boasts a full emergency department with three triage rooms, three trauma rooms, and 18 critical care beds; four surgical rooms; six pediatric rooms; 10 labor and delivery rooms; and a radiology wing with 14 imaging rooms.
"Admissions have been strong. The unit has been busy," Pulsipher says. "We have some beautiful rooms that are much better than at our old hospital that was destroyed. Our ORs are incredible. Our emergency department is gorgeous. We don't have as many inpatient rooms as we used to have, but it is still a very positive experience."
Pulsipher says building costs have made the interim hospital a "purely clinical facility."
"We didn't put anybody there that wasn't clinical. My office is not going to be in that hospital," he says. "Virtually all of our support services are going to continue to be distributed throughout the community. It was too expensive to build that hospital for all those support services as well."
With widespread and violent storms becoming an annual spring rite in the Midwest, Pulsipher says more rigorous building standards may be needed for new hospitals in the region. He says the $500 million Mercy hospital that will open in 2015 will spend an additional $15 million on storm-hardening.
"In California they do a much better job with earthquake codes than we do around here," he says. "So I think we will, in our part of the world, see new buildings become more storm-hardened and ready to take on those kinds of challenges."
In addition, staff at Mercy regularly drills for tornado emergencies. "We just let the patients know it is a drill, and we try to do it on sunny days so that nobody is worried," Pulsipher says. "That happens in just a few minutes and they take the patients to the corridors. There are some patients who are so fragile that we plan to just keep them in their rooms and make the precautions there."
Pulsipher says the rebuilding at Mercy has been particularly satisfying because it is moving in step with the rebuilding of storm-ravaged Joplin. "Our city has been very aggressive in making sure we get rebuilt and also working closely together," he says. "We have had a Community Advisory Recovery Team that has pulled together all segments and I have been very active on that. We have a community master developer that the community has hired to make sure we grow in an intelligent way together."
"When we decided where to site our new hospital we got community leaders together to help us decide where the best place might be for the community not just the hospital," he says. "We are much better integrated now than we were before the storm."
Since May 22, 2011 Mercy Health System has made all the right moves in Joplin. The health system moved quickly in the hours after the storm to bring in resources and reassure the stunned people of a devastated city that the hospital would continue to be there for them.
Mercy ensured that the 2,200 employees at the destroyed hospital would continue to work at other Mercy hospitals and even competitors' hospitals in the region. Leadership understood that a hospital is an important economic driver in any city and that the loss of several hundred jobs would make the recovery more difficult. Also, for practical purposes, they didn't want to lose a dedicated staff when they reopened.
That commitment has sent a powerful message. Through word and deed Mercy Health System is telling the people of Joplin, "we will rebuild together."
Hamburger giant McDonald's USA says that only 26 of its more than 14,000 fast-food restaurants in the United States are located on hospital campuses.
But in the view of one consumer advocacy group, that's 26 restaurants too many.
"We are calling on the administrators of the nation's leading hospitals and health institutions to bag the burger joints and create a healthier eating environment for children," says Sriram Madhusoodanan, national campaign organizer for Boston-based Corporate Accountability International.
CAI this month sent a letter to 22 hospitals with a McDonald's on their campuses, including Cleveland Clinic and Children's Memorial Hospital of Chicago, urging them to sever ties with the Golden Arches.
"The main reason we are launching this effort is because in hospitals, clinics, and doctors' offices kids are being treated for diet-related conditions like diabetes on one floor and being offered the world's most-recognized junk food brand on the next," Madhusoodanan says. "The practice earns McDonald's a very undeserved association with healthfulness among parents and children. It needs to stop."
Madhusoodanan says McDonald's marketers have taken a page from "the tobacco industry before it and worked to co-opt the voice of the health community."
"These hospitals where McDonald's is siting are essentially used as part of McDonald's comprehensive marketing strategy, and it's a strategy that is at its core inconsistent with the goals of the health institution. It's important that when people come to these hospitals that they have food environments that reflect the advice that their doctors and health providers are giving them and doesn't totally contradict it."
Not surprisingly, McDonald's has a different perspective.
"McDonald's promotes the idea that it's not about where you eat; rather, it's about what and how much a person chooses to consume during every eating occasion," Danya Proud, spokesperson McDonald's USA, said in an email to HealthLeaders Media. "We are proud of our menu and the actions we have taken to evolve the variety of choices we offer our customers, which have led our industry."
Proud said some meal combinations provide less than one-third of the USDA's daily recommendation for fat, sodium, and calories. The hamburger giant also provides easy access to nutritional and ingredient information in each restaurant and on the Internet. For example, the signature Big Mac, large fries and large coke carry about 1,350 calories.
"As always, we continue to assess our menu and actively engage in dialogue with experts to determine opportunities to offer expanded menu choices and additional information and education that enable our customers to make the choices that are right for them," Proud says.
Comparing McDonald's to the tobacco industry is a stretch. Nonetheless, CAI has resuscitated longstanding and legitimate concerns about the appropriateness of fast-food restaurants situated on hospital campuses at a time when more than 60% of Americans are overweight or obese.
In fact, many hospital administrators probably have already reached that conclusion. That's why we shouldn't be surprised if these 26 hospitals quietly look for other food vendors when it's time to renew franchise leases. It's likely that within 10 years McDonald's will have no hospital-based restaurants.
Vanderbilt University Medical Center was one of the first hospitals in the nation to have an on-site McDonald's. The Nashville, TN-based health system let its long-term lease with McDonald's lapse in January 2011 after a 20-year relationship and signed Au Bon Pain as a new tenant. John Howser, VUMCdirector of media relations, says pressure from CAI or other outside groups was not a factor in the decision to part with McDonald's.
"Ultimately what this came down to was a desire to offer a segment of our workforce and our visitors who would use this particular venue a broader array of food options," Howser says. "We already have a grill in our cafeteria in our clinic where hamburgers are available."
Cleveland Clinic spokeswoman Eileen Sheil says the blue chip health system will not renew its soon-to-expire lease with McDonald's. The decision is consistent with the comments and actions of Cleveland Clinic CEO Toby Cosgrove, MD, who created a stir in 2009 when he said in an interview that he would not hire obese people if it were legal.
Sheil tells HealthLeaders Media that "Cleveland Clinic as a healthcare institution tries hard to walk the talk in healthcare."
"So, we banned smoking on the campus. We no longer hire smokers. We supported the efforts for Ohio to go smoke free in public places. We've taken trans fats out of all of our cafeterias. We've posted calories. We took out our fryers. We made 40 to 50 changes in our cafeteria alone and in our patients' food. We provided in the community a couple years ago free access to the YMCA. We partnered with the YMCA, Curves, and Weight Watchers to offer free gym memberships and access to Weight Watchers for community members for six months," Sheil says.
"It was to focus on wellness and generate awareness over the premature causes of death which are caused because of smoking, obesity and lack of exercise."
"This issue with McDonald's is old news to us. It's not going to change anything we do," she says. "We are well on our way to creating the healthiest environment we can and to be a role model for healthy behaviors in the hospital industry and we have done a pretty good job. This lease is up soon and it's an old issue for us."
What we are hearing now from Howser and Sheil is what we can expect to hear in the coming months and years from officials in the 26 hospitals that still house McDonald's franchises. Hospital leaders are already weary of defending their association with McDonald's in those predictable interviews with the local TV news station that occur every time a group like CAI issues a press release. You've seen those spots. They invariably show shoulders-down and backside video of obese McDonald's customers waiting in line for a Big Mac fix.
No hospital wants to have the distinction of being the last in the United States to house a McDonald's. There won't be a grand announcement so much as a quiet parting of the ways. Hospital officials will deny or play down the idea that McDonald's fat-infused diet was a factor. After all, there is no need to bad-mouth a former business partner. It's just time to move on.
This has to happen. We know about the causes, effects, and costs of overweight and obesity. So it is indefensible for hospitals to continue to provide space for a restaurant chain that serves food linked to the health problems clinicians are treating just a few steps away. It's not just a mixed message. It's the wrong message.
Usually this column features success stories about community and rural healthcare leaders who are a force for good health, economic growth, and stability in their communities.
We cannot, however, ignore the gloomy "Side B" stories of hospital bankruptcies and closures that appear with unsettling regularity just about every day in newspapers across the United States.
That is what's happening now at Saint Catherine Medical Center Fountain Springs in Ashland, PA, a town of about 10,000 souls located 52 miles southwest of Wilkes-Barre. The 67-bed, investor-owned, acute-care hospital, which was built in 1967, this week filed an emergency petition for Chapter 11 protection in a federal bankruptcy court.
Because the filing was a rush job, it's still not clear how much the hospital owes, or to whom. That will be sorted out in the coming weeks and months.
Federal officials have appointed attorney William G. Schwab as the Chapter11 trustee of the medical center. He told local media that "when all is said and done 2012 will not be the date of the last admission." Schwab also said he hopes to "do what is right" for the employees, community, patients, physicians, and shareholders. He didn't have many details to share this early in the process.
Judging by news accounts, the bankruptcy filing seemed inevitable after the Pennsylvania Department of Health in March found deficiencies and violations that threatened patient health and put their safety in immediate jeopardy.
In a March 23 letter to Merlyn Knapp, the medical center's CEO, state health officials cited a lack of "proper equipment and supplies" for surgical services. "Until you can provide the department with evidence that the operating room equipment has been properly inspected, there is sufficient equipment, and there are adequate supplies, the ban on admissions also applies to your surgical services department."
Knapp said in a media release that "we do not agree with some of the findings and are currently working on a plan to address and appeal those findings."
It didn't matter. The state ordered an immediate ban on new admissions, surgical services and emergency and outpatient procedures.
Whatever else was left was not enough to keep the hospital running, so things went downhill from there. On April 3, the Centers for Medicare & Medicaid Services told Saint Catherine that because of the deficiencies identified by the state the hospital no longer met the federal requirements for participation in Medicare. That sealed the deal, and the hospital filed for Chapter 11 days later.
"We are evaluating all future options for Saint Catherine Medical Center, including a potential sale and re-opening of the hospital," Knapp said.
And now comes the fallout.
The bankruptcy filing left about 100 employees uncertain about their job prospects, or if they would get paid for the time they've worked, and vacation time accrued, etc. Local media reported a testy 25-minute closed-door meeting this week between employees and hospital owner Robert M. Lane.
Echocardiographer Christine Hamilton, who's worked 13 years at the hospital, told the local News-Item newspaper that the meeting was "a waste of time."
"All (Lane) said is he doesn't know anything and the bankruptcy lawyers would be handling everything. That was pretty much it. He pretty much talked in circles," she said. "He was asked why our money was stolen from us, and his answer was that he didn't know what was going on and that the CEO and the CFO were running the hospital."
Knapp said in a media release that the hospital intends to "do our best for our employees."
That includes a job fair next week that will focus on job retraining, adult education options, budget assistance and unemployment compensation.
"We are concerned for the welfare of our employees and have been working with the local Career Link Center and other organizations to provide a program that will enable our employees access to many different organizations," Knapp said.
It's not clear how the closing will affect healthcare delivery in Ashland and Schuylkill County, which was recently deemed to be among the least healthy counties in the Keystone State by the 2012 County Health Rankings & Roadmap survey.
The county surpasses the state average in negative measures of population health such as per capita premature death, obesity, smoking, and excessive drinking. And there are about 2,000 county residents for every one primary care physician, which is more than three times the national benchmark. So, it probably won't help health outcomes if there is one less hospital to serve the county.
And there is the fallout in lost tax revenues and trickle-down economic activity that comes with losing 100 or so relatively well-paying jobs in a somewhat remote county with an unemployment rate of about 8.5%.
We talk a lot about hospitals as powerful economic engines for most communities, and they are. Many of these hospitals provide quality healthcare and economic stimulus with a trickle effect that improves the lives of thousands of people in the service area.
Unfortunately, in this era of tremendous flux in healthcare, an equally urgent story is that of the hospitals that teeter on insolvency, with their employees, patients and the communities they serve left anxious, angry and confused about their job prospects, care access, and economic status.
The federal government's proposed rule that would delay for one year the implementation date for ICD-10 buys providers more time but does nothing to address underlying procedural problems that could wreak havoc when the diagnostic code set eventual goes live, one observer says.
"Yes, an additional year is going to be helpful. But it doesn't solve the underlying flaws in the current process," says Robert Tennant, senior policy advisor with Medical Group Management Association.
"Additional time only gets us to where we are now a year later. Our position all along has been the process itself is flawed. They never did a pilot. We need staggered implementation dates to build in the specific testing period."
If finalized, the one-year delay, detailed in CMS's proposed rule , means that ICD-10 standard would become effective Oct. 1, 2014.
"Many provider groups have expressed serious concerns about their ability to meet the Oct. 1, 2013, compliance date," HHS said in an April 9 press release . "The proposed change in the compliance date for ICD-10 would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets."
Federal officials had hinted in February that a delay was in the making, so the news Monday did not surprise key provider groups that had raised concerns about the pace of implementation.
"The American Medical Association and physicians across the nation appreciate that CMS has proposed delaying the ICD-10 implementation date to Oct. 1, 2014," AMA President Peter W. Carmel, MD, said in a media release. "The postponement is the first of many steps that regulators need to take to reduce the number of costly, time-consuming regulatory burdens that physicians are shouldering."
Carmel said the AMA is still reviewing the proposed rule and plans to issue formal comments to CMS on the delayed ICD-10deadline, "as well as the standard unique health plan identifier proposed in the same rule. A robust unique health plan identifier is an administrative simplification solution that has the potential to bring about significant cost-savings by eliminating the ambiguity that makes health care transactions so costly today," Carmel said.
Marie Watteau, director of media relations for the American Hospital Association, told HealthLeaders Media in an email exchange that HHS's announcement was "welcome news, especially for smaller hospitals. The AHA will continue to work closely with all of our members to support ICD-10 implementation."
Tennant says the federal government's "debacle" with 510(k) implementation demonstrates that everyone in healthcare "can't be vectoring toward the same compliance date."
"There has to be a way to get the plans and clearing houses ahead of time and then bring the providers on and have a period of time where there is testing and then you go live after the testing has taken place," he says. "This is not just about ICD-10. There are a whole host of mandates coming out of the Affordable Care Act, and if we don't improve the process we are going to be running into roadblocks at every turn."
"Also we as providers are so reliant on our software vendors and those folks, the practice management systems vendors, are not covered entities under HIPAA," he says. "What we would like to see happen is a certification process so there would be some guarantee that the software could handle the new codes and so we are going to be advocating for that."
MGMA's Tennant says he's not convinced that ICD-10 is needed in physician practices and he complained about "a lot of misinformation" on ICD-10 implementation from advocates for the code set.
"The standard line is we are the last country on earth to use this code set when the truth is no country uses this code set," he says. "The main countries that are cited, Germany, Australia and Canada, none of these three implement ICD-10 on the physician side. They only did it on the hospital side. I think the jury is still out on whether or not it is appropriate even to implement it on the physician side. There has to be more study done."
