One of the troubling ironies of nursing is that many of the people who dedicate their lives to healing patients do so at the expense of their own health. It doesn't have to be this way.
Hospitals can be dangerous work environments for healthcare professionals. There is the threat of exposure to an alphabet soup of hepatitis and tuberculosis strains, along with other dangerous pathogens. There is also the threat of violence and injury at the hands of angry, frightened, drugged out, drunk, and mentally unbalanced patients, their friends, and family.
And now a recent study in Journal of Nursing Administration that examined survey data from 2,103 female nurses has determined that 55% of them are obese. For context, 34% of adult Americans are considered obese, while another 34% are considered overweight but not obese, according to the Centers for Disease Control and Prevention.
Of course, there is no reason to expect that nurses should be exempt from the overweight and obesity epidemic that is plaguing this country. However, it is disheartening to learn from the JNA survey data that nurses are actually at greater risk than the general population.
Kihye Han, PhD, RN, the lead researcher for the study, and a postdoctoral fellow at the University of Maryland School of Nursing, says she was drawn to the topic when she first came to United States from her native South Korea and confronted our overweight and obese epidemic firsthand.
"I was shocked when I came here and saw so many people (more than half) who looked so heavy," Han wrote in an email exchange with HealthLeaders Media. "This was no exception in hospitals. (In Korea, the obesity rate is not as high as here.)"
It shouldn't be surprising because Han says nurses are "surrounded with obesity risk factors."
"First of all, hectic work schedules. Non-standard work schedules affect normal eating time and habits among nurses," she writes. "For example, night shift nurses require additional efforts to get healthy food and to access facilities for exercise, and they also eat junk food during their night shifts. Extended work hours make nurses sleepy and lack of sleep is an important independent risk factor for obesity."
"Moreover, nurses, a female-dominant workforce, have double care-responsibility at work and home," Han says. "They take care of their children at home and this is another stress source and requires support from work, e.g., providing day care service, modifiable work schedules for mom nurses."
Job-related stress and fatigue induces nurses to find comfort in sweet and fatty foods.
Han's findings are the latest in a series of University of Maryland School of Nursing studies examining nurse health and productivity and the linkage to quality of care. Other UMD studies led by Profs. Alison Trinkoff, Carla Storr, and Jeanne Geiger-Brown, have linked nurses' 12-hour shifts and irregular schedules with sleep deprivation, health problems, and patient-care errors.
"When I presented the preliminary results of this study at a national nursing conference in 2010, a lot of nurses showed me their interest," Han wrote. "They agreed their working conditions influence their eating/exercise habits and finally their weight. But also they said they felt nobody cares for their health, especially for their lifestyle-related health. Usually hospitals show attention for nurses' occupational health, such as needle-stick injuries. Nurses are assumed to have desirable lifestyles and be healthy and in addition, to be a caregiver rather than a care receiver."
Han believes that hospitals can take steps to create a healthier work environment for nurses. These could include educational interventions to make nurses aware of the risks they face, improvements to work schedule flexibility, and even instituting naps in the workplace to prevent sleep deprivation during 12-hour shifts.
Hospitals should also provide affordable and easy access to healthier foods, and give nurses sufficient time to eat properly, Han believes. In South Korea, for example, she says hospitals often offer free and healthy meals to nightshift workers.
"Some hospitals offer on-site farmer's markets to increase access to healthy food for healthcare workers who work nonstandard hours," Han says. "Healthy vending machine choices and food delivery services to the work unit can also increase food quality and access for nightshift nurses."
Of course, even the best preventive measures will fall short if the healthcare workplace is understaffed, Han concedes. "Sufficient staffing should be employed to provide nurses to decrease their workloads and job stress. However, we all know it's hard to make organizational level changes," she says.
In the end, adequate staffing levels will be the biggest obstacle because of the cost.
However, hospital and healthcare organization leaders who are reluctant to acknowledge or act on the problem of nurse obesity and overweight should remember that this isn't just about "employee wellness." There is more at play than the upfront costs of providing for a healthier workforce. This is also about reducing labor costs and medical errors while improving outcomes.
Healthier nurses mean reduced absenteeism and turnover. They provide better care and make fewer errors, all of which save lives and money.
The economy might be on the rebound, but the nation's hospitals should still brace for the possibility of $360 billion in cuts in Medicaid, Medicare, and other federally funded healthcare programs and services over the next decade.
Moody's Investors Service said in a credit outlook that the ongoing reductions in federal funding for healthcare in the fiscal 2013 budget and beyond could make it disproportionately more difficult and more expensive to borrow money for hospitals that rely on Medicare.
"If adopted, the cuts would reduce reimbursement to hospitals, forcing these institutions to continue finding additional expense savings or new sources of revenue to avoid the credit negative deterioration of their profit margins," Moody's said in a budget analysis.
"Most hospitals have been adjusting to negative credit trends since 2008, and many have improved their quality and efficiency substantially. But past operating savings reflect harvesting 'low-hanging fruit,' while future savings will be harder to achieve and will require more wrenching change."
Medicare rate increase reductions installed under the healthcare reforms will enter their third year when the fiscal 2013 budget takes effect in October. Over the next decade, Moody's says, about $268 billion in Medicare reductions could adversely impact funding for critical access hospitals, graduate medical education, and bad debt relief.
Moody's noted that the Medicare Payment Advisory Commission in January recommended a Medicare rate adjustment of 1% for the coming budget cycle, which is less than half the rate of inflation in the overall economy.
Lisa Goldstein, associate managing director at Moody's, told HealthLeaders Media that hospitals have done a good job confronting cost growth. "Low-hanging fruit examples would be reductions in work force, not filling existing positions, matching clinical needs with nursing skill sets better, looking at supply costs, negotiating bigger discounts with vendors, buying in bulk for example," Goldstein says.
However, she believes the "wrenching change" that hospitals may now have to undertake will be considerably more involved.
"'More wrenching change' speaks to the next level of cost reduction and expense management, which is more about gaining efficiencies. That is taking apart the fundamental basic building blocks of patient care and recreating them all over again in a more efficient manner," she says. "We have heard from providers across the country, examining how they deliver healthcare, the processes, the operations, the patient flow to become more efficient and extract permanent savings that way."
The federal budget also calls for about $52 billion in cuts to federal funding for Medicaid in the coming years. Moody's said those changes could include replacing current funding formulas with a single matching rate for each state, rebasing disproportionate share payments, and limiting the federal funding match for provider taxes.
"A limit on federal matches for provider tax payments would be a significant development because these programs have proliferated significantly over the past several years, and receive on a combined basis an increasing amount of federal support," Moody's said.
"Prior to 2008, 15 states operated provider fee programs. Today, this number has grown to 33, with another three states considering a program. These programs most benefit hospitals with high exposure to indigent populations and their elimination would negatively affect those hospitals the most," the report said.
Goldstein says the federal government could eventually shut down provider tax schemes as a cost cutting measure for the federal deficit. "Most hospitals realize that these provider tax programs may not go on forever," she says. "We look to hear how those hospitals and management teams will lower their reliance on these funds. How are you going to manage if this program abates one day?"
A proposed rule that would extend responsibility for Medicare overpayments through a 10-year "lookback period" is generating concern from healthcare providers.
The proposed rule, posted in the Federal Registry on Feb. 16 by the Centers for Medicare and Medicaid Services, implements a provision of the Affordable Care Act that details reporting and reimbursement guidelines for Medicare overpayments.
The lookback period now is generally about four years. CMS estimates that extending the review by another six years would cost as much as $58 million in reporting-related expenses each year for about 125,000 providers and suppliers.
The public comment period on the proposed rule extends through April 16.
Amy E. Nordeng, government affairs counsel for the Medical Group Management Association, told HealthLeaders Media that a 10-year lookback would create an undue burden for most healthcare providers.
"We wish it was shorter. We are going to argue that it should be shorter," said Nordeng. "For a group practice finding the records and having the same billing system in place 10 years down the road is pretty unlikely."
"Four years is much more reasonable because practices are used to that. You plan for the government being able to go back four years so you are able to develop processes for that," she says.
CMS said in the proposed rule that a 10-year lookback period would make it consistent with the False Claims Act statute of limitations and that the proposal is "appropriate for several reasons."
"First, we believe that providers and suppliers should have certainty after a reasonable period that they can close their books and not have ongoing liability associated with overpayment," CMS said. "We also believe that the length of the lookback period is long enough to sufficiently further our interest in ensuring that overpayments are timely returned to the Medicare Trust Funds."
Overzealous Oversight
Nordeng says CMS is a little too zealous. "To the extent where they are trying to find actual false claims where there was knowing intent to submit a false claim, they would still have that 10 years. But to attach that 10 years to the overpayment as well seems like overkill," she says.
Michael Gennett, of counsel at Miami-based Akerman Senterfitt Law Firm, told HealthLeaders Media he is urging his clients to voice their concerns during the public comment period.
"When we let our clients know there is a comment period for a proposed rule, usually I don't expect that somebody is going to take the time to shape the rule. But this is one that especially hospitals will want to weigh in on," he says. "The 10 years has a monetary impact obviously as far as how much you may have to return. But there's a practical impact of trying to go through records that go back that far. Most people may not have those records on site."
Linking the 10-year lookback to the False Claims Act isn't necessary, Gennett says, because most overbillings have no criminal intent.
"[Ten years] would be under the worst case scenario under the False Claims Act when in fact most of the time when there is some kind of billing error it is just that—an error. It is not a knowingly false claim," he says.
While the CMS proposal is alarming, Gennett says it shouldn't come as a complete surprise.
"The political environment we are in right now is one where the federal government is taking all kinds of measures to combat fraud and abuse in healthcare with the idea that we are going to save money," he says. "Most government agencies have taken a fairly aggressive stand and this would be an example of that."
The American Hospital Association and the American Medical Association also are drafting letters to CMS that will detail their opposition to the proposed rule.
"The AHA believes that hospitals need a workable solution to return overpayments. Unfortunately, the proposal will create new and unnecessary burdens and risks for hospitals, burdens and risks that go well beyond what Congress intended," AHA said in a statement.
"We are particularly concerned with the extraordinary expansion of a look back provision to 10 years and, what appears to be, an effort to effectively expand the reach of the False Claims Act beyond what Congress understood was necessary when it amended that statute to address overpayments in 2009."
We hear a lot these days about the challenges facing rural healthcare providers.
Those challenges are real and daunting. They include accessing technology and capital, finding qualified clinicians and other skilled healthcare workers and technicians, and providing access and wellness strategies for a population mix that can often be disproportionately poor, uninsured, unhealthy and isolated.
We should not forget, however, that rural healthcare providers are also creating innovative programs to overcome these many obstacles. These rural healthcare professionals are not sitting back waiting for someone else to solve their problems.
For example, Choptank Community Health System's six federally qualified health centers serving isolated communities along Maryland's Eastern Shore is using a $400,000 two-year grant from not-for-profit CareFirst BlueCross BlueShield to develop an intensive intervention program for noncompliant Type 2 diabetes patients.
CCHS believes the program will pay for itself with healthier diabetic patients requiring fewer emergency interventions and hospitalizations.
John R. Strube, CCHS's vice president of marketing and development, told HealthLeaders Media that most of the grant money will pay for two fulltime nurse coordinators to aggressively monitor treatment regimens for about 250 patients "whose A1Cs are seriously out of control."
"Diabetes is one of those illnesses that if you manage it well, you prevent a lot of damaging and expensive health problems, because the disease really does attack your whole system," Strube explained. "One of the challenges particularly for folks in the safety-net world or folks who have limited coverage is getting them involved in the kind of really intensive care you need to manage or prevent diabetes."
"The opportunity from CareFirst was particularly intriguing for us because they are focusing on doing things at the primary care level to manage chronic and multi-symptom diseases effectively and at a more cost-effective point in the care delivery system than having folks show up in the hospital in severe shape."
In addition to the individualized treatment plans and close monitoring, the intervention program will use group-centered disease management tactics that rely on peer support to maintain treatment regimens.
"Most insurance companies don't cover that very well but we made it clear to CareFirst that if this model works would you consider adapting your reimbursement model to cover this? They said yes," Strube says. "There is a real excitement about the partnership we are building."
CCHS will also use some of the money to devise financial incentives that will reduce care costs for the diabetes patients who maintain that regimen and meet health improvement markers.
"Part of what we are trying to do with this grant is to look at the problems our diabetic population faces and say if you join the program and are compliant and we see progress we will provide some form of incentive that, for example might help you offset the cost of your co-pay," Strube says.
About 80% of CCHS's 27,700 patients are at least partially insured, but that doesn't mean their costs are covered. "We have a fairly balanced case mix but a significant portion of our patients are economically distressed."
With the region facing tough economic times, Strube says it makes sense to offer financial incentives in a pilot program to keep cash-strapped diabetic patients on their regimen. "We offer greatly reduced costs for folks who don't have insurance, but it is not free," he says.
"Even for folks who have insurance, many employers are going to high deductible plans. So the first $1,000 might be out of their own pocket. When gas is $4 a gallon and you have to drive to get anywhere around here because there is no public transportation, people are oftentimes putting their co-pay in the tank to come and see the doctor."
What happens in two years when the CareFirst grant money runs out?
"Once the funding goes away we will have to look at how we can maintain an incentive program. That is the one wildcard in all of that," Strube says. "Our hope is that as we are able to demonstrate this we will along the way become certified as a diabetic education site with the American Diabetes Association. That will help us provide a service that is reimbursable with insurance. By capturing that reimbursement we should be able to sustain the program post grant."
Strube believes that a successful diabetes intervention program could also serve as a blueprint for treating other chronic diseases. All of this would help to reduce spiraling healthcare costs and alleviate other challenges that chronically understaffed and underfunded rural healthcare providers face.
"For our uninsured population, we don't generate a lot of revenue. The savings are to the system, not necessarily to us. Along the way, if we can show that we are bending the cost curve, we share in those savings," Strube says.
"The key thing is we know that if we can engage the patients and their families in making the investment to do the things they need to do, we know their health will improve."
About $36 billion could be shaved off the nation's healthcare tab each year if the cost for 300 common procedures covered under employer-based insurance plans were reduced to their median prices, according to research from Thomson Reuters Healthcare.
To do so, however, those healthcare consumers would need ready access to provider-specific price and quality information, including summaries of costs associated with the care, such as ancillary and hospital fees, and potential out-of-pocket expenses, the report says. Right now, that ready access does not exist.
"Increasingly the cost of healthcare is shared more significantly by the consumer," Raymond Fabius, MD, CFO of Thomson Reuters Healthcare, Inc., told HealthLeaders Media.
"One of the reasons why it is so important to promote the concept of transparency, both in terms of cost and outcomes, is so that people can engage in a much more sophisticated decision-making process between not only 'should I do this or not', but also 'with whom should I do it,'" he says.
David Shapiro, MD, president of the Ambulatory Surgery Center Association, supports transparency, but says trying to compare prices for healthcare is practically impossible right now because of its inherent complexity.
"I am a physician, and if I seek to purchase healthcare … I have the same problem that a non-physician patient would have trying to determine what that cost would be," Shapiro said.
"You may or may not know what your insurer will pay. You may or may not know what you pay for insurance. Possibly your employer writes the check. So you have huge firewalls between your hard earned money and purchasing healthcare," he said.
"Healthcare is not only the most important service you buy, it is certainly the most expensive and complicated. You mix all those things up and you essentially have the perfect storm and the patient who has the most at stake really has the least input and knowledge of the system," he says.
The study used insurance claims data for employer-sponsored insurance plans to analyze variations in prices nationwide for 300 "shoppable" high-volume elective procedures, such as a mammogram, colonoscopy or MRI. The claims data showed that some prices in some markets were two or three times higher than the median price for the same procedures.
The study identified site of service as another major driver of price variation. The costs of services done in hospitals are significantly higher than in the outpatient or office setting, and the study found nothing to indicated that higher prices correlated with higher quality of care.
Fabius says health insurance plans and providers need to drop their longstanding reluctance to hide their prices from the public.
"Getting that cultural change to occur will be a challenge," he says. "There is some good reasoning behind the interest on the part of providers and payers to negotiate privately. They believe their pricing schedule at least on the payer side may provide some competitive advantage."
"Ultimately marketplaces should be responding to the needs of the purchaser. The wind is in the sails for change and ultimately it will become clear to both the providers and the payers that in order to serve the needs of their ultimate customers, the purchasers and the consumers, they need to support greater transparency."
If consumers are expected to pick up more of the cost for their own healthcare, Fabius says simple fairness demands that consumers know those costs.
"There is the hope that because the consumer or patient has more ‘skin in the game' they may be more inclined to engage in comparative shopping," he says. "What is concerning is that without adequate price or quality transparency it is very difficult to shop even if you have skin in the game."
Nemours' brand new Children's Hospital in Orlando won't open until October, but the pediatric health system is demonstrating its commitment to patient- and family-centered care before the first child is admitted.
The health system has tapped into the wisdom and experience of a dozen or so parents of chronically ill children. Those parents volunteer to sit on a Family Advisory Board that meets with leadership candidates to gauge their commitment to the patient-and-family-centered mission.
"They may look great on paper. We can't judge that part. We can't judge their experience and their education background and their technical skills," says advisory board member Lynda Griffin of nearby Maitland, FL. Her six-year-old son suffers from cystic fibrosis.
"What we can do is part a gut feeling and part the candidate being transparent and open and also being open to working with the families," says Griffin, who has taken part in about 30 interviews. "One of my favorite questions for a candidate, depending on the job they are interviewing for, is if you think a parent should be there when something like a code is happening?"
"When somebody tells me that they do not think a parent should be in a situation where a child may be coding, or that there isn't a spot for the parent there, it tells me they're a little closed-minded to the whole patient-and-family-centered care collaboration with the Nemours team," she says.
Rick Kennedy, senior human resources business partner at Nemours Children's Hospital, concedes that he was a little leery when the idea of bringing parents into the interview process was first put forward.
"As an HR guy, yes, at the beginning I had a little anxiety. These are not folks with a lot of experience with interviewing," he says.
Nemours designed a two-hour interview skills program and brought in parents for training so they could be more comfortable asking the questions and better assess the candidates for leadership positions.
"We wanted to make sure they had some understanding of what is an appropriate question, how you structure it, and what are the inappropriate questions we want to stay away from," Kennedy says. "But having sat in on numerous interviews of candidates with the parents never once have I cringed or said 'Let's take a time out.' If I put a trained and experienced mom or dad in front of a leadership candidate I have no anxiety that they will do the right thing and ask the right questions."
The families on the advisory panel came with different backgrounds and experiences. "Some had business experience and had done interviews before, and others had never sat on the side of the table with the interviewers. They had been interviewees," Kennedy says.
Regardless of their backgrounds, Kennedy says the parents' input is highly valued because the HR professionals and medical staff cannot replicate the unique perspective of a parent with a chronically ill child. "From an HR perspective they bring something very real to the table as we are assessing candidates," he says. "When we think about the care of a child there is a partnership between the parents and the doctors the nurses and allied health professionals. We thought it was hugely important that parents have a voice in who we are bringing on as leaders.
Just how important is the parents' input on leadership candidates?
"In HR, there are a lot of touch points through the hiring process," Kennedy says. "The family perspective on a candidate is weighed very heavily. This is not cursory. It is not presenting the parents with an opportunity and then arbitrarily dismissing their thoughts. It has really set the tone, not only for who we hire, but how critical the parent is in partnering with us. It's been absolutely phenomenally successful in my view. The parents are hugely invested in this."
Griffin says it's a "privilege" to play a vital role in the leadership selection for the new 95-bed hospital, which will have nearly 600 employees when it opens this fall. She says having parents take part in the selection process also sends a clear message to the candidates.
"We want them to see that it is not just visiting with the physician and the nurse but also taking it to the next level of care all around; from the minute you walk through the door to the time you leave it is patient-and-family collaboration."
"The nurses and physicians do what they do really well. But we know our kids really well and that helps overall because you're getting another person that is part of the team looking out to make this child get better."
Federal inspectors are calling for tighter oversight of waste, fraud, and abuse in Medicare Advantage after a first-ever system-wide audit of the program found wide disparities in vigilance and reporting among the privately run plans.
"Our findings indicate that Medicare Advantage organizations lack a common understanding of key fraud and abuse program terms and raise questions about whether all Medicare Advantage organizations are implementing their programs to detect and address potential fraud and abuse effectively," the report said.
The audit from the Department of Health and Human Services Office of Inspector General reviewed 2009 data from 170 of the 188 Medicare Advantage organizations that represented 4,547 plans nationwide and accounted for 94% of the 10.9 million Medicare Advantage beneficiaries in 2009.
The audit did not name the Medicare Advantage organizations.
Three Medicare Advantage organizations identified 95% of the 1.4 million incidents related to their Part C health benefits and Part D drug benefits that year, while 19% of the organizations reported no potential fraud and abuse. Overall, Medicare Advantage plans sent only 2,656 referrals of potential fraud and abuse for further investigation.
"Differences in the way organizations defined and detected potential fraud and abuse may account for some of the variability in the number of incidents they identified," the audit stated. "While CMS requires MA organizations to initiate inquiries and corrective actions where appropriate, not all MA organizations took such steps in response to incidents they identified."
Auditors recommended that the Centers for Medicare and Medicaid Services take action to ensure that Medicare Advantage organizations effectively monitor fraud and abuse.
Those steps would include:
Determining why some plans reported especially high or low cases of suspected fraud and abuse;
Developing guidelines for plans to define potential Part C and Part D fraud and abuse;
Requiring plans to give CMS aggregate data related to Part C and Part D antifraud, waste and abuse activities;
Requiring Medicare Advantage plans to refer potential fraud and abuse to CMS or other investigators.
In a written response to the audit, CMS Acting Administrator Marilyn Tavenner agreed with most of the findings and noted that CMS has already begun enhanced auditing of Medicare Advantage organizations to detect fraud and abuse. Tavenner said, however, that CMS does not have the statutory authority to require mandatory self-reporting of fraud and abuse by Medicare Advantage organizations.
Medicare Advantage covers about 24% of Medicare beneficiaries and accounted for $115 billion of the total $504 billion in Medicare benefits in 2010, OIG said.
In an era of constrained budgets, however, the program and its mounting costs have come under more scrutiny from the federal government. The Medicare Payment Advisory Commission estimated that CMS spends about 10% more on beneficiaries Medicare Advantage plans than it does for beneficiaries in traditional fee-for-service Medicare.
HHS in its 2010 financial report identified a composite payment error rate of 14.1% for Medicare Advantage programs.
While 33 of the 170 organizations audited detected no fraud or abuse, another 24 organizations identified only Part C fraud incidences and 11 organizations identified only Part D incidents. These 68 organizations covered a total of 571,623 beneficiaries.
For the 137 Medicare Advantage organizations that reported fraud and abuse, the volume varied widely. Fourteen organizations each identified more than 1,000 incidents while 41 organizations identified fewer than 10 incidents, the audit said.
One organization accounted for 78% of the total 1.4 million incidents of potential Part C and Part D fraud and abuse. Excluding the 95% of all reported incidents that were linked to three Medicare Advantage organizations, 134 organizations identified a total of 73,499 potential fraud and abuse incidents in 2009. Of those, 83% were linked to Part C. Those 134 organizations covered 9.9 million beneficiaries in 2009.
Size apparently was not a factor in organizations' ability to monitor waste and fraud. "For example, an organization with more than 250,000 enrollees identified 37 potential Part C fraud and abuse incidents and 8 potential Part D incidents. Another organization, which had fewer than 5,000 enrollees, identified 7,787 potential Part C fraud and abuse incidents and 154 potential Part D incidents," OIG said.
The 134 Medicare Advantage organizations reported 32 different types of Part C incidents in 2009. The most common related Part C was improper coding of services. The organizations identified 25 different types of potential fraud and abuse related to Part D, and inappropriate prescription dispensing was the most common.
Alcohol abuse is a "significant problem" for surgeons in the United States, with more than 15% of respondents in a nationwide survey signaling that they may have dependency issues, the American College of Surgeons reports.
The survey in the February issue of Archives of Surgery found that the rate of alcohol use disorders among the 7,197 responding surgeons is slightly higher than that of the general U.S. population.
For surgeons reporting dependency issues, the survey found there was a "strong association" with problems in personal and professional relationships that included burnout, depression, and medical errors. In fact, the study found that nearly 78% of surgeons reporting a medical error in the previous three months also had issues with alcohol abuse or dependence.
"Our goal is not to scare the public. That is the last thing we want to do. But we also want to say that people are paying a really high price," says Krista L. Kaups, MD, a coauthor of the survey, Prevalence of Alcohol Use Disorders Among American Surgeons.
The study recommends that healthcare organizations and professional associations, including the American College of Surgeons, develop early warning and intervention programs that identify problem drinkers and provide treatment and therapy options. "These findings should also decrease the shame and stigma associated with alcohol abuse or dependence and encourage surgeons to pursue treatment and rehabilitation to promote patient safety and personal well-being," the study said.
"We want people to be aware of this because we want to be able to honestly look at ourselves and say here is the issue we need to support people," said Kaups, chair of the American College of Surgeons Governors Committee on Physician Competency and Health.
Kaups says substance abuse problems may be particularly insidious and difficult for surgeons to admit. "There is the idea that ‘I can take care of crazies and disasters, so I am in control. The alcohol is just to take the edge off because I deal with enough things,'" she says. "We also know that in general, the characteristics we value in our professional lives, things like perfectionism, commitment to patients, those things put people at risk of burnout as well."
Alcohol disorders target female surgeons particularly hard. The survey found that 25.6% of female surgeons indicated that they have alcohol use issues, compared with 13.9% of their male colleagues. By contrast, in the general population, 9.4% meet the criteria for alcohol and substance abuse, including 10.5% of men and 5.1% of women.
"Part of it is that female surgeons on the whole are less likely to be married or in a supportive relationship," Kaups says. "It is changing as we look at the younger surgeons. But the lack of personal and social support is a really key thing when you are dealing with difficult and challenging issues."
The anonymous online survey is the latest in a series of studies the American College of Surgeons has undertaken recently to assess members' stress, burnout, and other job pressures. Kaups says failure to address these problems could have significant repercussions for patient safety and access.
"We have people who are not functioning at their best in terms of taking care of patients optimally," she says. "We find people who are struggling with these issues are less likely to stay in practice. We have a workforce shortage already so we have to figure out how to allow people to function at their best and continue in practice."
The survey was sent to 25,073 surgeons, and the 7,197 surgeons who responded represent a sampling of less than 29%. A critique of the study that also appears in the February issue of Archives echoes the survey authors' concerns that the low response rate could skew the findings.
Edward Livingston, MD, a professor of surgery at the University of Texas Southwestern Medical Center in Dallas, wrote that the response rate was about half the 60% minimum required by some medical journals. Thus, he wrote that it is impossible to say if the problem is being over-reported or underreported.
"Surgeons who abuse alcohol are at risk for livelihood-threatening sanctions should this behavior be exposed. Despite reassurances of confidentiality, questionnaire responses may still be considered risky by surgeons with much to lose," Livingstone wrote.
Livingstone said that several types of bias and error may be at play in any survey, but the most obvious one is nonresponse. "Nonresponse bias is particularly salient when the topic is considered sensitive," he wrote.
Kaups concedes that the accuracy of the survey could be questioned because of the low response rate, but she's standing by the findings.
"This is a huge group of people who we studied. What we don't know and what we can theorize about is a possible sampling bias," she says. "Did we get people who respond who are having issues and feel like they can express themselves, or are these people who feel pretty good about themselves? We don't know but we think it is a reasonable survey. It was anonymous online. People are honest about what they say."
The Obama Administration this week announced a new "memorandum of understanding" between federal bureaucracies that they claim will help rural healthcare providers build their healthcare information technology workforce, which is expected to grow by 20% by 2016.
In a vaguely worded press release, the White House said "the Department of Health and Human Services and the Department of Labor signed a memorandum of understanding to connect community colleges and technical colleges that support rural communities with the materials and resources they need to support the training of Health Information Technology professionals that work in rural hospitals and clinics."
HRSA Administrator Mary Wakefield, RN, said in the media release that: "This memorandum of understanding with our colleagues at the Department of Labor will build on existing collaborations to help ease the challenges of geographic isolation and staff shortages faced by rural communities and help move us toward our mutual goal of Health IT workforce development."
Federal Health Resources and Services Administration officials did not return calls by deadline Wednesday so details remain sketchy.
Randy Smith, president of the Rural Community College Alliance, says he's not really clear on the specifics of the MOU, and only learned of it when HealthLeaders Media called. Still, he's happy the federal government is acknowledging the challenges that rural healthcare providers and educators face.
"Community colleges don't get a lot of attention and [if] you take it another notch further, rural schools get even less attention," Smith says. "We aren't in a media market. We aren't in a population center. The first step in making our case is letting the general public know what we are doing. So we are pleased that the administration is shining a spotlight on community colleges and rural community colleges in particular because we haven't had that before."
There are nearly 1,200 community colleges across the United States, and Smith says more than 60% of them are "rural serving." Those colleges will play a big part in educating the rural healthcare HIT workforce.
"Two-year colleges are really good at responding to the needs of the communities we serve. We are able to change and adapt our academic programs as needed," Smith says. "I don't know of a rural community college that is not actively participating with their local healthcare providers to make sure their needs are met. Without these rural community colleges, many of these allied healthcare professions and first responders and technical programs would not happen. We just would not have those professionals."
Not surprisingly, Smith says the big issue for rural community colleges is funding. "Finances are always an issue but it is not something that can't be overcome with partnerships. The local healthcare providers are very good at working with community colleges to share some of that cost," he says. "So that is an issue but most of the time if they need specific types of healthcare providers they usually step up to the plate and help their community college with the cost. That is happening now."
Finding students, however, is not an issue. Smith says there are plenty of eager students in rural areas who'd love to work in healthcare HIT. However, resources can't accommodate everyone.
It's fairly similar to the nursing shortage," he says. "The students are there. It's just the fact that we have to have the clinical sites, the on-campus facilities and the faculty to produce those professionals. It's the same way with HIT. We know the students are there. We've seen it. But we have to ramp up and have the facilities and faculty and clinical sites to make that happen."
"The availability of clinical sites for rural areas has always been an issue too because of the distances involved," he says. "Our rural hospitals can only take so many students and give them a good experience. Sometimes our students have to travel a ways to more urban or suburban settings to get their clinical experience and that can be a challenge."
"Faculty recruitment is not the highest thing on the list but there are times when recruiting qualified, experienced healthcare faculty to rural areas can be a challenge," he says.
When asked what the federal government can do to help rural community colleges train HIT professionals, Smith had a ready answer: "Obviously grants and funds are always welcomed."
However, he acknowledged that government budgets are tight and that "we have to learn to make do with what we have and do the best we can and try to partner with business and industry."
If the federal government does release more grant money, Smith says that funding should specifically target rural community colleges.
"They will release a grant for a specific program or specific service, but it is hard for us to compete against the urbans and suburbans because they have professional grant writers," he says. "Our folks wear three or four different hats at our rural schools and we haven't had grants targeted for rural schools."
Smith says an RCCA delegation that will include 25 rural community college presidents will visit Washington, DC next week to meet with federal officials on several fronts. If the federal government works with rural community colleges, Smith says, those colleges are capable of producing an HIT workforce.
"Local community colleges are the catalyst for economic development. They are a clearinghouse for information for rural communities," he says. "If we can get those federal agencies to understand that fact, it is a benefit to everybody, including them."
The average per capita cost of healthcare services covered by Medicare programs and commercial insurance grew by 5.28 % in 2011, nearly double the rate of inflation in the larger economy, Standard & Poor's Healthcare Economic Indices show.
A further breakdown of S&P data shows that healthcare costs covered by commercial insurance plans grew by 7.11% in 2011, while Medicare claim costs rose by 2.51%, despite the government plans' older and sicker population.
Healthcare costs easily outpaced the 3% growth in overall inflation as measured by the Consumer Price Index for 2011, according to Bureau of Labor Statistics data.
Robert Zirkelbach, a spokesman for America's Health Insurance Plans, told HealthLeaders Media that commercial plans must contend with cost-shifting and other market forces that do not affect Medicare. He says the cost growth acceleration also could be link to the recovering economy.
"When the acceleration slowed in the last couple of years, a lot of it had to do with the slowdown in the economy," Zirkelbach said. "People were using fewer healthcare services. That also resulted in changes in the risk pool, where younger and healthier workers chose to forego coverage, or when employers were laying off employees it was often the younger workers that tended to be the first to go. So that resulted in a risk pool that tended to be older and have higher healthcare costs."
J.D. Kleinke, a healthcare economist with the American Enterprise Institute, says higher deductibles, co-pays and premiums have been slowing cost growth by forcing healthcare consumers to be frugal.
"The 10-year trend is that healthcare is normalizing," Kleinke told HealthLeaders Media. "The standard deductible 10 years ago was $200. That was the same deductible as in the 1950s. The deductible for health insurance didn't change during a time when everything else in the economy went up by an order of magnitude. The health insurance industry accommodated a huge amount of waste. People used it more than they needed and physicians were more than happy to deliver more care than needed because it was somebody else's money."
"It took 20, 30, 40 years to get out of control. Then the reaction in the 1990s was to blame the doctors and the hospitals and beat them up and do this utilization review stuff, and that didn't work. Now for the last 10 years it's been the demand side," Kleinke said.
The S&P indices also show that month-to-month healthcare cost growth accelerated in December, up from +4.85% in November to +5.28% in December. Commercial plan costs increased from +6.63% in November to +7.11% in December, while Medicare costs increased from +2.15% in November to +2.51% in December.
David M. Blitzer, chairman of the Index Committee at S&P Indices, said in the report that costs are trending back toward acceleration after a lull in November.
"Since the end of the summer we have generally seen increasing annual growth rates, particularly with healthcare costs covered by commercial plans," Blitzer said in the report. "Last month's data, which was through November 2011, showed a modest deceleration; however, December's data has returned to the accelerated pace and this time it affected all types of healthcare costs.
The S&P Healthcare Economic Indices estimate the per capita change in revenues accrued each month by hospital and professional services facilities for services provided to patients covered under traditional Medicare and commercial health insurance programs.
The annual growth rates are determined by calculating a percent change of the 12-month moving averages of the monthly index levels versus the same month of the prior year.
Blitzer said healthcare costs began to accelerate in May 2009 and peaked in May 2010, before decelerating through the first half of 2011.
"Since then, growth rates started to once again accelerate, most notably for hospital costs and those covered by commercial insurance plans," Blitzer said. "In fact, our Hospital Commercial Index stands out as the one whose annual growth rate, +7.95%, is back to its May 2010 rate. We appear to be entering 2012 witnessing a renewed acceleration in healthcare costs."
Zirkelbach says health insurers should not bear the blame for rising healthcare costs.
"S&P is focusing on the price issue, not utilization," he says. "You're seeing healthcare cost growth not being has high as it used to be but that was due to decreased utilization, not prices. Prices continue to go up."
"As the trend of hospital consolidation continues we are seeing that it results in higher prices as more and more hospital systems attain dominant positions and are able to dictate terms," he says. "That is having a big impact as well."
