Ochsner Health System CEO Patrick J. Quinlan, MD, understands the unease that many people feel with the potentially invasive nature of workplace wellness programs.
How far may employers intrude into the lives of workers in the name of lower healthcare costs and higher productivity?
For Quinlan, however, the clear point of demarcation is smoking.
On April 1, the New Orleans-based, eight-hospital health system and its more than 13,000 employees marked their one-year anniversary as a tobacco-free workplace. HealthLeaders Media spoke with Quinlan this month to mark the anniversary and record his broadside against tobacco—one of the biggest sources of preventable death in the United States.
"I am sympathetic to the idea of 'where do you draw the line?'—which is both true and a debating tactic that attorneys and anybody else can use to reduce something to the absurd," Quinlan says.
"This has nothing to do with eating Hostess Twinkies. This has nothing to do with anything other than a poison that shouldn't be here today," he says. "This is a scourge that has somehow become normal and the costs are enormous. In Louisiana alone it's $3 billion in lost productivity and 6,500 people dying directly. This is all tangible. You can't say that if someone gained a pound or didn't walk around the block."
Quinlan contends that smoking occupies "a wildly different category" where the individual's right to smoke should not outweigh the health menace and financial burden tobacco imposes on others in the form of higher health insurance premiums, medical costs, and lost productivity.
"We are getting into your life because what you do in your life is directly paid for by me," he says. "If you go home and watch television I don't pay for that. You don't send me the bill for your cable. No, that's your business. The demarcation between rights and responsibilities and who carries the costs is a fairness issue."
"This has been flipped to where somehow my right to choose what I want to do has been translated to my right to make everybody else bear the cost of my choices," he says.
As for efforts to eradicate smoking among Ochsner employees, Quinlan says the self-insured health system's approach includes premium discounts for employees who don't smoke and cessation support for employees who do.
"Repeated studies show that people want to quit smoking, but it is an addictive behavior and usually the more you push on people in a way that generates resistance, you don't help them. There has to be acceptance for there to be change," he says. "And the tack that we take is that this is an unfortunate and addictive habit that people develop early in life often with the acquiescence of government and society."
Quinlan is particularly incensed by laws in Louisiana and more than two dozen other states—pushed by Tobacco industry lobbyists—that prohibit employers from discriminatory hiring policies against smokers.
"We have a tobacco cessation person we are hiring to run our program but we could not stipulate that the person who leads this had to be a nonsmoker. That is kind of bizarre," he says.
The physician-executive says laws protecting smokers work at cross purposes with societal efforts to reduce healthcare costs. Studies show that smokers can cost employers as much as $3,400 a year in increased healthcare costs and lost productivity. "Often at the local, state, and federal level there is this intense scrutiny on the cost of healthcare. Yet we are particularly silent on the leading cost of avoidable death and disease in this country," he says.
"Our position is, if government can't help in this regard, at least get out of the way of employers and employees trying to decide how they best can preserve benefits for everybody."
"The broader issue is we see what is happening with healthcare costs. We really need to avoid those diseases that we have control over so we can save the benefit and costs for those who have diseases for which they have no control."
As resolute as he is against smoking and its destructive costs, Quinlan is also puzzled by the view of some that the battle for a smokeless society has already been won. "Smoking is embedded in this country and we need to recognize that it is a battle thought to have been won but it is far from over," he says.
"I hear people say 'well it's really not a problem anymore is it?' When over one-in-five people smokes and the death tolls and the destruction and the cost is enormous, we have become so accustomed to it that something like one out of five is deemed OK. What is so odd about this is that the poisonous nature of smoking and the addictive nature are so clear, the cost is so high, yet we are relatively indifferent to the magnitude of that threat."
Quinlan suspects that any premature victory celebration in the war on tobacco comes from the generally better educated and wealthier people who don't smoke. "The people I often associate with say there is no smoking," he says.
"None of my friends smoke, but in fact studies clearly show that the poorer you are the more you smoke. The blacker you are the more you smoke. The more mental illness you have the more you really smoke. So it's that invisible underclass that smokes. It is the underclass that has the worse outcomes. That is more than a coincidence. It's cause and effect."
Quinlan says that at some workplaces, the one-in-five people who still smoke should not be surprised if coworkers pressure them to quit or move on. "People won't mind intervening with you and saying 'Hey listen. It's not fair. We are struggling to maintain our benefits and you are literally burning them up. So if you want to do that fine. Just don't work with us anymore please. I don't want to pay your bill,'" he says.
The healthcare sector created 26,000 jobs in March, a precipitous deceleration in growth when compared with the first two months of 2012, new federal data shows.
Even with the slowdown, healthcare job growth is outstripping the pace set in 2011. The sector created 101,800 jobs in the first quarter of 2012 compared with the 61,000 jobs created in the first three months of 2011, the Bureau of Labor Statistics reports.
Healthcare remains a major job growth engine in the overall economy. In the first quarter of 2012, healthcare accounted for 16% of the 635,000 jobs created in the United States. March recorded 8,100 new jobs in hospitals, and 12,100 new jobs in ambulatory services, which included 7,600 jobs in physicians’ offices.
Dawn Murphy, senior vice president, human resources for Saint Luke’s Health System says the Kansas City, MO-based provider increased full-time equivalent staff by 6.59% in 2011. The system has 9,500 employees. That employment growth is continuing in 2012.
"We have seen a growth in our employment because of two things. No. 1 we are seeing our volumes increase. Our newest hospital, which is St. Luke’s East, is on a new expansion and they’re hiring for that. We are building another unit on our newest hospital," Murphy says.
"And also as most health systems our size are doing we are integrating physician practices. We are hiring and when we bring on the physician practice we bring on the employees as well. So, our employee population is growing from organic growth and integration of physician practices," she says.
Murphy says there is also continued demand for healthcare IT staff to help implement meaningful use and address other issues related to electronic medical records. "We are always looking for good clinical IT people, just like everybody else," she says.
Revised BLS figures show that healthcare created 42,200 jobs in February, continuing a strong trend in job growth that saw 296,900 payroll additions in 2011. Healthcare accounted for more than 18% of new jobs in the overall economy last year, BLS data shows.
Murphy says the drop in healthcare job growth in March could be linked to most health systems’ budget cycles. "This may be too simple an answer but there is a little bit of a pent up demand until budgets are approved," she says. "If a hospital is on a calendar year budgets get approved in late fall, December and they have these new FTEs they have approved. So we tend to have active hiring because we have positions that have been approved in the budget process."
More than 14.2 million people worked in the healthcare sector in March, with more than 4.8 million of those jobs at hospitals, and more than 6.2 million jobs in ambulatory services, which includes more than 2.3 million jobs in physicians' offices.
In 2011, the 296,900 jobs created by healthcare represented more than 18% of the 1.6 million jobs created in the overall economy that year.
BLS data from February and March are preliminary and may be revised considerably in the coming months.
In the larger economy, the nation's unemployment rate dropped from 8.3% in February to 8.2% in March, with 120,000 new jobs reported for the month. BLS said the jobs created in March came mostly from healthcare, manufacturing, and food service.
Even with the modest gains, BLS said 12.7 million people were unemployed in March, slightly improved 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 5.3 million in March, and represented 42.5% of the unemployed.
When it comes to wellness, Hernando, MS Mayor Chip Johnson says it is the individual's responsibility to stay healthy through proper nutrition and regular exercise.
"But I do believe you can't exercise your responsibility for good health if your city or the county you live in does not give you an opportunity and an atmosphere for that good health," the mayor says.
Johnson made his remarks in a teleconference with reporters at Tuesday's launch of the 2012 County Health Rankings. The rankings were compiled and published by the Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin.
For those unfamiliar with the Rankings, which for the past three years has examined and ranked more than 3,000 counties in 50 states, it's worth a look.
The Rankings detail county-by-county health measures including per capita education, income, rates of smoking, obesity, sexually transmitted diseases, and the ratio of primary care physicians per county residents. This year the Rankings include new measures such as the number of fast food restaurants in a county and levels of physical inactivity among residents.
Patrick Remington, MD, an associate dean at the University of Wisconsin School of Medicine and Public Health, says the ranking provide a broader perspective of a county's wellness by measuring health behavior, clinical care, social and economic factors, and physical environment.
"What the rankings tell us is that while access to medical care is critically important, (population health) is affected by much more than what happens at the doctor's office," he says. "This shows us that where we live matters to our health."
Remington wants cities and neighborhoods to use the rankings to identify and solve their particular problems. "After three years we are seeing that these rankings are changing the conversation about health in communities from one focused mainly on treatment or sick care to one that involves a more complete view about how we promote health through our communities, schools and workplaces," he says.
In Hernando, a city of about 12,000 people located south of Memphis, TN, community wellness is incremental and improves with each new bike path, sidewalk, and nutritional program.
The city requires any new development or redevelopment to include access for bicycles and pedestrians and not just cars. Hernando doesn't have money for new recreation and sports facilities, so the city is partnering with schools to use their gymnasiums after school for programs such as basketball leagues. Fourth- and fifth-graders in the city's schools have accepted Johnson's challenge to join him and other city officials in running a marathon—one mile at a time.
The city situated a farmers' market within walking distance of the poorest neighborhoods. "We have to give access to healthier food. We can't expect people to eat healthier and be healthier if they don't have access to those foods. So a farmers market is one way to do that," Johnson says. "And you have to make sure your farmers market is in places that are within reach of your poorest communities, your underserved communities."
Customers can pay for their fresh produce using social assistance such as WIC and low-income senior vouchers. "Don't make your farmers market just something for people with money," Johnson says.
On other wellness fronts, city officials talked Renasant Bank into donating 40-acres of land that it was sitting on after a development deal flopped. The land will be used for a new park named after the bank.
"All across the nation banks are sitting on land they repossessed and they don't know what to do with it," Johnson says. "So I would suggest that all of these neighborhoods go out and ask a bank to give that land to your city to make it a park. You might even name that park after the bank."
The city got a $5,000 grant to build a bike path a half-mile long. Johnson says that's not a very long bike path, but "every little bit helps." The city is also working on ways to "get under the interstate so town is not literally divided in half for pedestrian use."
Johnson says the city is already enjoying a return on investment from its new wellness program for city workers. "Last year we were struggling to find a way to increase the pay of our city employees," he said.
"Suddenly we got our renewal rates for the health insurance premiums and because of the efforts our employees had made to be healthier, our health insurance premiums decreased 15%. And with that windfall we were able to pass that along as a 2% pay raise for our employees. Very literally employees' healthy practices gave themselves a pay raise."
Hernando was named the healthiest hometown in the Magnolia State in 2010 by the BlueCross BlueShield Foundation of Mississippi. Johnson says he's using that honor as an economic development tool.
"When I want to recruit businesses to come to my town, I need to be able to show them that when they move here they are going to have healthy workers who will show up for work every day, and that that they will have workers whose health insurance premiums will be lower, which will go straight to the bottom line," he says.
"We are seeing that people very literally are moving to our town and our county because they perceive it to be a healthy town. That is the best compliment one could get, when people say 'I am moving to your county or city because I want to be in a place that is healthy.'"
It is refreshing to see that Johnson and the city of Hernando have an unabashed willingness to think small when it comes to wellness. There is not some grand, etched-in-stone master plan built by pricey consultants to promote health in Hernando, MS. Instead, there is a commitment to an idea of wellness that they're convinced works. From that commitment come the incremental steps that make Hernando a better, healthier place to live.
"Some of these things may sound small, but it is these small things that build up to a culture of health," Johnson says. "These things just tend to build on one another."
Health Management Associates this week finalized a deal that will give the Naples, FL-based hospital chain an 80% controlling stake in five Integris Health Oklahoma hospitals.
Financial terms were not disclosed for the deal, which was finalized April 1.
"We are very pleased to partner with Integris Health and welcome these five hospitals into the Health Management family," HMA president/CEO Gary D. Newsome said in prepared remarks.
The deal is just the latest in a string of acquisitions of not-for-profit hospitals by for-profit hospital companies in all parts of the country. It's a trend that shows no sign of slowing down. The 2012 HealthLeaders Media Healthcare Mergers & Acquisitions Survey found that 78% of healthcare leaders say they will have deals under way or will be exploring deals in the next 12–18 months. (Download the free, full report here.)
Earlier this year Moody's Investors Service noted the significant challenges that not-for-profit hospitals continue to face, including:
Pressures on hospital revenues coming from a variety of sources, including Medicare, Medicaid, and commercial payers
The myriad challenges brought on by healthcare reform, including the transition to a new care delivery model and the uncertainties that come with it, and the increase in physician employment
The soft economy, which will continue trends in lower utilization, high unemployment, and increase reliance on charity care, self-pay, and government payers.
Ongoing investment losses caused by volatile bond and equity markets, pension fund obligations, increased capital spending funded with cash reserves, increased exposure to non-cancelable operating leases, and negative valuation of swap portfolios.
Moody's also noted that mergers and acquisitions generally strengthen health systems' balance sheets, improve management, governance, and efficiencies, and provide an exit for bond holders.
The Integris Health hospitals are: 53-bed Integris Blackwell Regional Hospital; 64-bed Integris Clinton Regional Hospital; 25-bed Integris Marshall County Medical Center, in Madill; 52-bed Integris Mayes County Medical Center, in Pryor; and 32-bed Integris Seminole Medical Center. The five hospitals total 226 licensed beds and generated about $95 million of net revenue, before the provision for doubtful accounts over the past year.
HMA subsidiaries operate 71 hospitals with about 10,600 licensed beds in non-urban communities in 15 states. Not-for-Profit Integris Health Oklahoma is the state's largest health system. Approximately six out of every 10 Oklahomans reside within 30 miles of an Integris Health facility.
This article appears in the March 2012 issue of HealthLeaders magazine.
Within the next five years, experts believe that patients will have—or will come to expect—near immediate Internet access to medical imaging as part of their personal medical records.
That push toward more access to imaging has caused some trepidation within healthcare circles as primary care physicians, radiologists, administrative staff, and even healthcare economists try to determine how it will alter the physician-patient relationship, what new demands and constraints it will place on physicians, and how it will impact the use and cost of expensive medical imaging.
David S. Mendelson, MD, FACR, chief of clinical informatics at Mount Sinai Medical Center in New York City, says improving patient access to imaging is something that all physicians—including radiologists—should embrace.
"The intent is to push for more appropriate imaging. The goal is, through easier accessibility you reduce redundant imaging," says Mendelson, who serves on the Radiology Informatics Committee of the Radiological Society of North America.
"You need the right information available when you're evaluating a patient. One reason there is 'inappropriate' imaging is lack of access to prior exams," he says. "You can spin a variety of clinical stories where someone wants the images or the results, or frequently both, and they aren't available and the only answer is to repeat the exam. That is costly, and in the case where there is ionizing radiation—CT is a common example—there is an extra radiation dose. And there is clearly a parallel drive right now to reduce radiation exposure to patients and use only as necessary."
Mendelson is also the principal investigator for the RSNA Image Share network, which offers patients Internet access to their medical imaging through a secure portal. The pilot project has enrolled patients at the Mount Sinai Medical Center, the University of California–San Francisco, and University of Maryland Medical Center in Baltimore. The Mayo Clinic in Rochester, MN, and the University of Chicago Medical Center will soon enroll patients.
The Image Share network all but eliminates the need for patients or attending medical professionals to travel to their physicians' offices to request or retrieve compact discs containing their medical imaging—which is the cumbersome and standard method of delivery at most healthcare facilities right now.
"The patients who have embraced Image Share are very positive about the expediency of using the Internet to replace a whole set of manual processes," Mendelson says. "This is not instantaneous gratification, but it is relatively quick and convenient. It cuts through a lot of manual processes."
Nagging doubts
Mendelson says there is growing support for improving patient access to all medical records, including imaging. However, he and other healthcare leaders concede that issues remain to be solved.
A paper about a survey released in December for the OpenNotes medical record pilot project that was initiated by Beth Israel Deaconess Medical Center in Boston found that patients were overwhelmingly interested in accessing their doctors' notes, but physicians were less receptive.
There also are concerns about utilization. Will facilitating patient access to their medical records increase their demand for more services and procedures, including costly CT scans, MRIs, and other imaging that may not otherwise be warranted?
"That is the question of the hour, and it remains to be seen," Walker says. "A lot of times we underestimate how resourceful patients are. Certainly knowledge is power in other arenas, so you could argue it either way. I can't deny the possibility but I hope the preponderance of evidence will be that people use this information well."
Steven P. Cohen, MD, an associate professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine, has studied the overuse of medical imaging in spine care, which he says often adds little value but adds significant costs. He says it's critical that increased patient access to medical records does not lead to more inappropriate imaging.
"The use of imaging does not seem to affect decision-making or improve outcomes in the large majority of individuals," he says. "So while I think that patients have a right to know the results of tests done on them, I don't think they should be the ones who decide on whether they are indicated—unless they are paying for them."
Ted Eytan, MD, MS, MPH, a director for the Permanente Federation at Kaiser Permanente, says facilitating patient access to their medical imaging will help to educate the patient and demystify the technology. "What will happen now is they will start to understand the limits of imaging," he says.
"Sometimes these imaging reports come back and do not reduce the uncertainty that the patient has, and the patient thinks, 'Why did I spend two hours in a box if this was not a justifiable expense that didn't change the condition?'" Eytan says. "Especially if they are going to pay for this, they are going to ask questions: 'Why are we doing this?'"
Walker agrees that cost-shifting will make for more discriminating patients. "The incentives are going to be different, so it seems like a well-informed patient could spend money more wisely as patients are spending more out of pocket," Walker says.
"And it certainly seems logical to have patient eyes on what is going on with care so that they could head off some errors early if a patient spots something wrong. It would provide opportunities for patients to say, 'I don't need a test. I already had it, and here are the test results right here,'" she says.
Image maker makeover
Increasing patients' access to medical imaging will also raise the profiles of radiologists—many of whom now have little, if any, contact with patients.
Mendelson acknowledges that some radiologists probably got into the subspecialty specifically to avoid patient interaction. That will have to change, he says, "and I believe that change may be a good thing.
"This will raise awareness of the profession to the general patient community," Mendelson says. "One of the pushes of our professional societies over the last few years is to let the patients know who we are. A lot of patients are not fully aware of who radiologists are or that we are even physicians. This is a way of raising awareness."
That higher profile will also carry some new responsibilities, Mendelson says, including "making yourself available and spending time that you don't spend today more directly encountering the patients. But perhaps in the big picture, that is a good thing."
Eytan says that more direct contact with patients will make radiologists better physicians.
"Radiology is a service profession. In this new era, they may not yet realize how valuable their service will be to the actual patient," Eytan says. "In the past they were serving other doctors, but I think they understand quite well what the future is."
Eytan compares increasing patient access to imaging to that of opening laboratory records to patient review. Similar concerns were raised at the time, but that access is now part of standard operating procedure at most healthcare systems and has cast a new appreciation from patients on the value of pathology and other lab services. He says medical imaging will see the same growth in stature from patients.
"I would tell radiologists that this is going to help the people you serve understand just how much you contribute to their care. It's going to make you look great," he says. "And the second thing is, if you never do it, you'll never know how much better your care can be because you'll keep talking in this arcane language, things will keep falling through the cracks, and you won't learn how to be a better radiologist."
Mendelson says that the increased visibility of radiologists carries "a lot of positive ramifications" that could help the profession in its pitched battles against reimbursement cuts from the federal government.
"There is the generic good will between patients and physicians," he says. "Secondarily, patients might become more appreciative of their radiologists and assertive toward their politicians to make sure that radiologists are treated reasonably."
Dumb down the data
Mendelson says he is not overly concerned that radiologists might have to alter the case notes they provide for imaging in electronic medical records to account for patient access.
"We believe patients are entitled to see their reports, but it will be a balancing act," he says. In the long run, he says the process will improve communication and efficiency.
"As more patients leverage seeing their results, will there be a feedback loop? Where will radiologists get more demand on their time to deal with patients? Will they find ways to rephrase things to generate fewer questions? That may well happen. But I wouldn't call it 'dumbing down' as much as finding the appropriate phrasing."
As an additional safeguard—at least initially—the RSNA Image Share network has a 72-hour delay on releasing new medical images to the patient until results and images can be communicated to the referring physicians. The delay was designed in part to protect patients from potentially devastating or confusing news without a ready interpretation of the data.
Mendelson acknowledges that the program designers knew such a delay would be controversial "because there were times when people needed these things instantaneously."
However, he says, the system designers also were being pragmatic.
"When we set this up initially we knew that we couldn't do everything in one fell swoop perfectly. We had to set priorities," he says. "The 72 hours was something that we recognized would require further refinement. We wanted to get the programming right for moving images around first. Now we can come back and revisit things that need to be a little more granular."
For Eytan, patient access to medical imaging is inevitable and part of the greater move toward access and transparency in healthcare delivery. Rather than debating the pros and cons of that patient access, Eytan says physicians should spend their time trying to make it work.
"It's not the 'if,' it's the 'how,'" he says. "This should be done, and the 'how,' I have learned, is everyone needs to be involved. The subspecialty of radiology is very important so this should not be done without their involvement. If we allow them to be involved, they will do a great job with primary care doctors to make this happen."
This article appears in the March 2012 issue of HealthLeaders magazine.
The public should be excused if, drawn into the endless news coverage of last week's U.S. Supreme Court arguments on the constitutionality of the individual mandate, they mistakenly think that healthcare reform centers around legal issues.
And the fierce debate on the presidential campaign trail over the merits and faults of the Affordable Care Act, and the often superficial media reporting on that debate, could also lead the public to mistakenly view healthcare reform as primarily a political issue that hinges upon who wins in November.
However, neither politics nor constitutional challenges are driving healthcare reform. In fact, delivering better healthcare, while certainly desirable , isn't even the main driver of healthcare reform.
What's driving healthcare reform? Follow the money. It's all about what we can and—increasingly what we can no longer—afford.
Regardless of how the Supreme Court rules, or who wins the White House this fall, or which party controls Congress in 2013, or whether it's "ObamaCare" or some improbable Medicare voucher scheme, or some form of muddled political inertia, the economic pressures forcing the issue now will still be there in the coming months and years.
The stats on healthcare costs are familiar. The rate of growth in healthcare spending in this country is unsustainable. According to the Kaiser Family Foundation, healthcare costs grew from $256 billion in 1980 to $2.6 trillion in 2010, and healthcare spending now consumes about 18% of the nation's gross domestic product. Although healthcare spending growth has slowed of late, thanks largely to reduced utilization during the economic downturn, that growth still easily outstrips general inflation.
For three decades we have been living in an era where healthcare "cost containment" has been a euphemism for passing the buck to healthcare consumers. Kaiser Family Foundation reports that since 2001, employer-sponsored health insurance premiums have grown 113%.
It's not hard to see why wage growth is stagnant. Payers are stressed and tired by this arrangement, and they are demanding reforms. That's not going to change if the Affordable Care Act is overturned.
Rather than hypothesize about what may change if the individual mandate is struck down, or if a Republican or a Democrat is in the White House, we should focus instead on the constants of healthcare that will still be in place in the coming years regardless of what happens between now and November.
"The constant is going to be the focus on the federal budget deficit and the continued increase in healthcare costs," says Dean Diaz, vice president and senior credit officer at Moody's Investors Service. "Regardless of what happens in the Supreme Court now there will be continued debate on how to rein in the growth in healthcare costs."
In other words, don't expect your Medicare reimbursements to keep pace.
Diaz says the strategies in place now in the for-profit hospital sector won't change much regardless of what happens in legal or political arenas. "There may be some tweaking of strategies here and there. But the focus on trying to operate more efficiently, having strong market position, those strategies will play either way," Diaz says.
"It will still be important to have a strong market position because you want to be in a position of strength in negotiations with commercial insurers," he says. "So at a local basis, market position is still going to be very important, and maybe even more important given the continued pressure on the growth in the commercial reimbursement."
Diaz says providers understand that they're going to be asked to do more and for less money. "Any efforts to continue to trim costs and operate more efficiently but still effectively clinically are going to remain a focus again no matter what happens in Washington. Especially on the government payers, the focus on the deficit and the spending levels for healthcare are absolutely going to pressure reimbursement from government payers," he says.
"It's already resulted in slower growth in recent periods and it's only going to become a bigger discussion as some of these proposals to trim the deficit come back to life."
Patricia Webb, senior vice president and CHRO at Catholic Health Initiatives, says the Denver-based health system remains focused on the use of primary care physicians and allied care professionals, such as nurse practitioners to improve population health and promote wellness.
"At the rate healthcare costs are growing we had to modify how we take care of patients and focus more on population health and preventive care that is going to happen and that is what needs to happen from our perspective," Webb says.
"It is driven more by the economics of it and if for some reason the Affordable Care Act is not passed and whatever happens the population is still going to need to access healthcare and we have to be in a position to provide it. The best way to do that is to do it in a way that provides the quality that needs to be provided, with appropriate access in a cost effective way," she says.
Webb says CHI isn't "putting anything on hold" as the system and its 70,000 employees look to the future.
"We know that even today and projected into the near future we are going to have continued shortages with primary care physicians, nurses, and other allied health professions," she says. "We are not going to stop recruiting those professionals or looking forward to address those issues. That's the direction we're moving in, and I think that is true for healthcare in general. If we stay focused, I think we'll be fine."
An 'unconscious' racial bias by some physicians could harm relations with African-American patients and ultimately may impair health outcomes.
A study in the American Journal of Public Health found that primary care physicians who held these unconscious racial biases spent more time with African-American patients during routine office visits, but also spoke slowly and dominated the conversations.
As a result, African-American patients queried by the researchers said they felt less respected, less trustful, and less engaged in the decisions related to their health.
"It could negatively affect the patient because although the visits tended to be longer and the doctors were talking slower the patients reported feeling less involved in the decisions," says Lisa A. Cooper, MD, a professor in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine, and lead author of the study.
"What we know from other studies looking at those kinds of indicators is that when patients don't feel as involved in decisions about their care they are not as likely to follow through on what is recommended to them, or come back for follow up visits."
Cooper and other researchers examined audio recordings of office visits among 40 primary care physicians and 269 patients in Baltimore-area medical practices. The recordings were from earlier studies examining care regimens for patients with chronic diseases such as hypertension and depression. The patients were mostly middle-aged women, and 80% were African-Americans. Of the physicians, 48% were white, 30% were Asian, and 22% were African-American. Two-thirds of the physicians were women.
The researchers used the standard Implicit Association Test to assess the physicians' unconscious racial attitudes. The physician took two versions of the IAT—one related to race bias and one that assessed whether the physicians thought patients of different races were compliant with medical advice.
"I don't know if these physicians were aware that they were acting this way because of the unconscious stereotype," Cooper says. "I don't think we were quite prepared for the finding that when physicians would have that unconscious stereotype, it almost seem like they were trying to compensate by talking more slowly and lecturing the patients. That was surprising."
Cooper says there is a lack of awareness in the general public as well as among physicians about this unconscious bias. "A lot of people feel on a conscious level they have very positive attitudes about people of different racial and ethnic backgrounds. So they don't feel on a conscious level that there is a problem," she says. "But we are socialized in such a way that these unconscious biases are there from an early point in our lives. We don't realize that we are behaving in a certain way."
To make her point, Cooper, who is African-American, says she took the IAT and it showed that she had a slight bias against African-American patients.
"I grew up in Africa and spent time in Europe before I came to the United States. I thought of myself as so multicultural. I have lived with so many different people. Surely I wouldn't have any unconscious biases," she says. "I found out of my test I had a slight preference for whites over blacks."
Cooper says she was surprised at the extent to which the patients sensed the bias in the study. "When there was more bias, particular the African-African patients talked of feeling less respected, not as well liked and felt like they didn't trust the doctor as much. Even though this was not overt, there was something patients could pick up on."
Cooper recommends that physicians take the IAT to learn if they may be harboring unconscious biases. The test is free and confidential and can be done online. If the test determines that a bias exists, Cooper says that does not make the physician a racist or a bad person, only human.
"Our experience has been that when physicians are made aware that something they are doing is not resulting in a good impression with a patient they are more than willing to try something different," she says.
"You don't say 'I can't appear racist' because when you do that you raise the patient's anxiety level so they behave more poorly," she says. "We focus on the positive. 'What is the best way I can behave in this interaction to make sure this person knows I value his opinion?'"
To confront her own biases, Cooper says she does a quick self-assessment before meeting with patients.
"I question myself before I move forward in my interaction," she says. "What assumptions am I making about this person where I could be wrong? Just doing that is an excellent first step. Have people make sure they stop and question their assumptions and ask themselves 'Am I behaving any differently than I would if this person appeared to be different?'"
A California appeals court this month ruled that certified registered nurse anesthetists in that state do not need physician supervision to do their jobs.
It's a clear victory for rural hospitals in California that have complained that requiring physician supervision of CRNAs adds unneeded costs and limits the range of surgery services they can provide.
The March 15 decision by the First District Court of Appeal in San Francisco really isn't a surprise. California is already one of 16 states that have opted out of a federal mandate that denies Medicare reimbursements to hospitals that allow CRNAs to work without physician supervision. Republican Gov. Arnold Schwarzenegger opted out in 2009, and his Democratic successor Jerry Brown supported the decision.
The suit was brought by the California Medical Association and the California Society of Anesthesiologists and it's not clear if they plan an appeal. CMA on its website says it is "disappointed with the decision" and is "exploring all legal, regulatory and legislative options."
Not surprisingly, California Hospital Association spokeswoman Jan Emerson-Shea told HealthLeaders Mediathat CHA was "very pleased by the decision."
There has been a lot of back-and-forth arguing between CRNAs, anesthesiologists, and CHA about whether or not patient safety is compromised when states opt out of the supervision requirement. Obviously, in a perfect world, it's always preferable to have the highest-trained medical professionals administering or supervising care.
It's not clear, however, if any studies show that patient care suffers when CRNAs provide unsupervised care.
Besides, this case isn't about patient safety, or even access to care. It's about money.
The savings in compensation costs and the money generated by additional procedures could be considerable for rural hospitals. Merritt Hawkins & Associates, the Dallas, TX-based national physician recruiting firm, says that first-year financial packages for anesthesiologists range from $275,000 to $350,000, while CRNAs earn around $200,000.
"Obviously the return on investment is there. It's a simpler search. There are more CRNAs in the marketplace than there are anesthesiologists," says Sam A. Karam, division vice president for Merritt Hawkins. "From a sheer dollars-and-cents standpoint it always makes sense to have CRNAs. Now, that is the main reason we have seen CRNAs being more in demand."
Karam says anesthesiologists were once among the most-highly sought after medical specialists. That is no longer the case.
"From a demand perspective, is it difficult to find anesthesiologists today? No. That's a stark change from just a few years ago when the demand for them was extremely high," he says. "You will find some that actually aren't even working in permanent positions. They're working locum jobs to stay afloat."
CRNAs are not the main reason for the slowing demand for anesthesiologists. Larger factors, including the long-sputtering economy and the anticipated changes that will come with healthcare reform, have "flip-flopped" market demand away from specialists and towards primary care docs.
Demand for anesthesiologists has dropped, Karam says, because demand for elective procedures has dropped. "That obviously was a great deal of the profit margin that a lot of surgeons were seeing when they opened their own surgery centers. With that market dipping, it took away a lot of the profit margin and a lot of the demand," he says.
"In addition you have hospitals being far more aggressive in communities than they have been before. The consolidation of medicine has really pushed hospitals to go out in their communities, buy up these surgery centers, or at least partner with these organizations and be a stronger player in their own backyard, so that they aren't losing those profitable procedures when they are there," he says.
Of course, many of the same economic forces that are hurting anesthesiologists are also hurting CRNAs, but Karam says CRNAs are having a "far easier" time finding work, and it all boils down to labor costs.
"They are still even higher in the locums demand market than anesthesiologists. They are in a much more comfortable position simply because what they can do, what the law allows them to do, and what they are commanding for pay," Karam says.
Perhaps the best hope for anesthesiologists is if CRNAs get too greedy.
"Paying CRNAs will change once they start to lobby and demand higher salaries," Karam says. "Once it gets up there to $250,000 or what an anesthesiologist can make, then obviously hospitals or medical groups will be more comfortable paying that money to a physician rather than an allied professional."
As for the California ruling, it's hard to see how this could end up differently. Many rural hospitals are running on razor thin margins. Medicare and Medicaid are trimming reimbursements, and private plans have adopted zero tolerance toward cost shifting. The hunt for savings is prompting hospital administrations to reexamine every aspect of care delivery, as they should.
Again, if there is no conclusive evidence to show that patients receive substandard care or are placed at greater risk under CRNAs, rural hospitals that provide bread-and-butter surgical procedures should not have to pay considerably more for the services of an anesthesiologist.
Anesthesiologists commanded top compensation during a robust economy. Like many other professionals, however, they may have to readjust their expectations. Perhaps it is time for them to make compensation demands that are more compatible with the market.
Cleveland Clinic this week is using the city's professional football stadium to field a three-day recruiting blitz to hire 600 new registered nurses.
The Stanley Shalom Zielony Institute for Nursing Excellence organized the job fair both to fill vacant posts and to proactively prepare for anticipated new demands that will come with healthcare reforms.
Cleveland Clinic CNO Sarah Sinclair says it's the first time the prestigious health system has attempted a recruiting drive this big.
"Part of this is to put the brand of our nursing institute out there in the community so that people get an opportunity to see many of the great things we are doing," Sinclair said in an interview. "We are putting the face of nursing to the community. It also gives all of these folks an opportunity to see our various hospitals and what each of the hospitals has to offer."
"The other thing we've been able to do is through some of our national benchmarking, to really get our arms around what the demand side is for our business," she says. "We have the process well orchestrated and nothing will be done any differently than it is in the normal recruitment process."
The job fair runs March 28-30 at Cleveland Browns Stadium. Demand should not be a problem. Sinclair says more than 1,180 nurses have preregistered for the event and she is anticipating many more nurses will visit the event as "walk-ins."
"Those are folks who are either new graduates, experienced nurses, nurse leaders, or nurses who will be graduating in the near future," Sinclair says.
Cleveland Clinics employs more than 11,000 nurses system-wide. Of the 600 new hires, 400 will be for existing positions, and 200 will be for new positions. All of the jobs are in the Northeast Ohio Region of the Cleveland Clinic Health System.
"We ask each of them to spend four hours with us," Sinclair says. "We will go through all the normal steps they would go through in the recruitment process which includes the obvious things, lab work, the physical exam, background checks, and of course go through an interview with the areas of choice they want to apply for. We do have a physical capacity assessment to make sure that our nurses are able to do the jobs we are asking them to do."
Sinclair says the biggest demand for nurses at the Clinic right now is in medical surgery, advanced practice nursing, imaging, intensive care, and nurse leadership, but that the changing landscape of healthcare means that other specialty areas may soon be in demand.
Successful candidates will be offered a job contingent upon their passing the physical and background checks. Smokers need not apply. Cleveland Clinic announced in 2007 that it would no longer hire tobacco users.
Sinclair says she'll consider the job fair a success if she can "fill every position I have open and have them started within a 60-day period and then retain them by the end of the year."
The last five years have seen a great expansion in the workforce and the acute nursing shortage is over, for now, according to a study published in the New England Journal of Medicine this month.
But the need for nurses is expected to surge again as the economy improves, older nurses retire, and more people seek healthcare as a result of healthcare reform.
An insurance industry study, touted as the largest of its kind, shows that medical costs can be reduced by more than $1,800 a year for each diabetic patient who receives periodontal care.
The study examined medical records from more than 1.6 million people who were covered by both United Concordia Dental and Highmark Inc. and identified about 90,000 Type 2 diabetics. About 25% of those diabetics elected to receive periodontal treatment in 2007 and the study compared their medical costs over the next three years with the 75% of diabetics in the group who declined the oral care.
"The data is striking. In 2007 you had fewer than half the inpatient admissions if the patients had periodontal surgery when compared with the patients who did not," says Marjorie Jeffcoat, DMD, with the University of Pennsylvania, the lead author of the study.
"I also found it striking that this result was carried through for three years," Jeffcoat told reporters at a Monday teleconference. "If you look at the mean number of visits they paid to a physician, again in 2007 they saw half the number of physician visits and this statistically significant result was carried through again for three years."
"If we look at mean medical costs we have a reduction in all three years and if you look at it the mean medical savings was $1,814 per patient per year. That is a striking number. This affect is apparent two years after the periodontal treatment," Jeffcoat says.
The study's release coincided with United Concordia launch of a diabetes-specific program that provides 100% coverage for surgical procedures, other treatments, and maintenance for patients with gum disease.
"This is the most statistically conclusive study proving the relationship between oral health and medical cost savings. The savings are just the start of what is to come," United Concordia COO/President F.G. "Chip" Merkel told reporters. "We believe that employers will realize reduced medical costs when their employees with diabetes receive appropriate periodontal care."
James Bramson, DDS, chief dental officer for United Concordia, noted that about 25.8 million Americans have diabetes, a number that has doubled since 1999. He says the sheer size and scope of Jeffcoat's study shows "that the results here are not a fluke."
"We did some modeling to look at the ability to take care of these kinds of patients and the cost of doing that and what kinds of savings you'd have on the medical side," Bramson says. "In a group of about 200 members, even as small as that, it would only take about 3% of the diabetics to actually return the savings on the medical side equal to what it would cost to provide these additional treatments. Beyond that all the rest is healthcare savings."
While the study examined diabetics, Bramson says other studies have provided linkage between oral health and coronary artery disease, cerebral vascular disease, and even premature and low-weight infants. "We believe other chronic diseases will show some association, some economic savings medically if those people had periodontal treatment," he says. "So when we know more about the breadth and depth of the accuracy of that savings across those other diseases our hope here is to broaden the coverage we are now starting with diabetes."
"The thought is you don't need to cover everybody in the population," he says. "The better thing to do is cover those targeted populations where we can show savings and where we know an intervention program of information and assistance will help them get in and get the treatment they need."
Bramson says dentistry accounts for about 4% healthcare spending in the United States, while hospital care, physician and clinical services, and drugs account for 63% of all spending. "If we can improve the spending in the dental that is going to affect the three other largest segments of the healthcare spending, so we believe you will have some savings well beyond the $1,814," he says.
The study did not specifically examine the cause-and-effect relationship between periodontal disease and diabetes, but Jeffcoat says earlier studies have explained the linkage.
"Any sort of infection you have, be it pneumonia, a kidney infection, it makes your diabetes worse," she says. "Periodontal disease is an infection. If we can get that infection under control we tend to get the hemoglobin A1C, the measure of three months of diabetes, under control. It has to do with inflammation and infection and getting it under control."
