Medicare funding cuts under consideration by Congress could cost the nation's hospitals $61.4 billion over the next decade, forcing them to trim their payrolls of nearly 278,000 jobs, the American Hospital Association said this week.
The reimbursement reductions detailed in H.R. 3630 would take funding from hospitals and use it to cover the deficit created by the extensions of the Social Security tax holiday and unemployment benefits, and by the so-called "doc fix" that aims to address cuts to physician reimbursements .
An analysis done for AHA by the researcher firm Tripp Umbach determined that if the provisions of H.R. 3630 were implemented, hospitals could see a reduction in funding of nearly $20 billion, along with about 83,000 job losses.
In addition, the study found that the mandatory sequestration that is scheduled to go into effect in 2013 could cost hospitals another 194,000 jobs and more than $40 billion in funding.
"Cuts in funding for hospital care will threaten jobs at a time when our nation needs to be creating jobs, not eliminating them," AHA President/CEO Rich Umbdenstock said Wednesday in a media release. "H.R. 3630 would lead to further job loss in hospitals, an ill-advised move in these tough economic times."
The Bureau of Labor Statistics reported this month that hospitals created 89,100 jobs in 2011, more than double the 37,300 jobs hospitals created in 2010.
In addition, AHA officials fear that hospitals may be caught in the political crossfire between the Obama administration and the Republican-controlled House. The AHA supported the Affordable Care Act and agreed to about $155 billion in funding cuts over the next decade in exchange for expanding healthcare coverage.
"The $155 billion was really tied to coverage expansion—that as coverage expands, there will be 31 million more people covered under Medicaid and the private exchanges and that provides an offset to some of the cuts in the $155 billion," Caroline Steinberg, AHA's vice president of trends analysis, told HealthLeaders Media.
Republicans on the House Ways and Means Committee, however, have openly dismissed the AHA's claims as alarmist. Last month the GOP leadership on the committee issued a press release stating that the cuts proposed by H.R. 3060 represented 0.5% of the $2.6 trillion in projected Medicare spending over the next decade, "hardly a 'major reduction.'"
"Not so long ago, the major hospital trade associations endorsed and strongly supported legislation that became law. It contained $155 billion in hospital Medicare cuts—more than 10 times the reductions in H.R. 3630," the GOP media release said.
A GOP staffer on the Ways and Means Committee told HealthLeaders Media Thursday that the House leadership stands by the points made in the media release.
Steinberg says hospitals are "very concerned about how this is going to shake out between figuring out ways to fund the physician fix."
"We are already facing a 2% sequester and then of course even with the sequester there will be more deficit reduction in the coming years. On top of that hospitals are seeing a lot of pressures from states on the Medicaid front," she said.
AHA officials fear the cuts in H.R. 3060 are a continuation of a larger assault on the nation's hospitals.
"The $155 billion that AHA put on the table for the Affordable Care Act was our attempt to show that it had to be a sacrifice for everybody," AHA Board Chair Teri Fontenot, the president/CEO of Woman's Hospital in Baton Rouge, LA told HealthLeaders Media.
"If you are going to get something—which we wanted more insurance coverage for uninsured patients—then you have to be willing to give something up. But everybody has a stake in this and each group ought to be looking at how they can work together."
"There really is a problem here financially, but to continually go after one segment of healthcare over and over again is patently unfair and enough is enough. That is why we are pushing back so hard on this right now," Fontenot says.
Fontenot adds that hospitals are hoping not to fall victim to the Beltway partisan politics.
"The healthcare sector is always in the cross hairs. It is such a huge piece of the federal budget and the federal deficit," she says. "And because the government is somewhat removed from providing the services. They've got the providers and the payers between that. I don't think they can appreciate the impact because they aren't working personally with the recipients."
She said hospitals are trying to play it down the middle and "work with everybody in Congress." That starts at the local level.
"We are constantly encouraging our members to work closely with their Congressional delegation members and staff, particularly when they are at home," she says. "We need to put pressure on them at home and explain to them very articulately what the consequences of the aggregate decisions that are being made at the federal level. It needs to be brought down to the patient level and how it affects that member of Congress's constituents, regardless of party affiliation."
Thomson Reuters on Tuesday named its "15 Top Health Systems" in the nation based on clinical performance.
The fourth annual study reviewed clinical outcomes at more than 300 health systems across the country and picked the top 15 based on a composite score of eight measures of quality, patient perception of care, and efficiency.
"This year we are seeing stronger system-wide performance and increased rates of improvement, particularly among the 15 Top Health Systems award winners," Jean Chenoweth, senior vice president for performance improvement and 100 Top Hospitals program at Thomson Reuters, said in a statement.
"Health system performance is beginning to reflect aspirations to provide more consistent outcomes across communities served. Healthcare reform appears to have stimulated the increased rate of improvement at the system level."
The study divides the 15 top health systems into large, medium, and small groups based on total operating expenses. The winners are as follows:
Large Health Systems
More than $1.5 billion total operating expenses:
Banner Health, Phoenix, AZ
CareGroup Healthcare System, Boston, MA
Jefferson Health System, Radnor, PA
Memorial Hermann Healthcare System, Houston, TX
St. Vincent Health, Indianapolis, IN
Medium Health Systems
Between $750 million-$1.5 billion total operating expenses:
Baystate Health, Springfield, MA
Geisinger Health System, Danville, PA
HCA Central and West Texas Division, Austin, TX
Mission Health System, Asheville, NC
Prime Healthcare Services, Ontario, CA
Small Health Systems
Less than $750 million in total operating expenses:
Baptist Health, Montgomery, AL
Maury Regional Healthcare System, Columbia, TN
Poudre Valley Health System, Fort Collins, CO
Saint Joseph Regional Health System, Mishawaka, IN
Tanner Health System, Carrolton, GA
Thomson Reuters says its study looked at eight metrics that gauge clinical quality and efficiency: mortality, medical complications, patient safety, average length of stay, 30-day mortality rate, 30-day readmission rate, adherence to clinical standards of care (evidence-based core measures published by CMS), and HCAHPS patient survey score.
The study found that regardless of their size the top health systems shared many of the same qualities, including:
Lower 30-Day Mortality Rates
The 15 top health systems held post-discharge 30-day mortality rates steady. Peer health systems showed a significant increase in post discharge mortality.
Better Survival Rates
Top hospitals had 17% fewer deaths than expected considering patient severity, while non-winning hospitals had 4% more deaths than expected.
Fewer Complications
Patients of top health systems had 19% fewer complications.
Shorter Hospital Stays
Patients treated in top systems have an average length of stay of 4.7 days, nearly half a day shorter than their peers' median of 5.1 days.
Better Patient Safety and Core Measure Adherence
Top health systems had 23% fewer adverse patient safety events than expected and had better adherence to core measures of care than their peers.
The study used the 2010 Medicare Provider Analysis and Review (MedPAR) and the CMS Hospital Compare data sets to examine health systems with two or more short-term, general, non-federal hospitals; cardiac and orthopedic hospitals; and critical access hospitals.
Thomson Reuters on Tuesday named its "15 Top Health Systems" in the nation based on clinical performance.
The fourth annual study reviewed clinical outcomes at more than 300 health systems across the country and picked the top 15 based on a composite score of eight measures of quality, patient perception of care, and efficiency.
"This year we are seeing stronger system-wide performance and increased rates of improvement, particularly among the 15 Top Health Systems award winners," Jean Chenoweth, senior vice president for performance improvement and 100 Top Hospitals program at Thomson Reuters, said in a statement.
"Health system performance is beginning to reflect aspirations to provide more consistent outcomes across communities served. Healthcare reform appears to have stimulated the increased rate of improvement at the system level."
The study divides the 15 top health systems into large, medium, and small groups based on total operating expenses. The winners are as follows:
Large Health Systems
More than $1.5 billion total operating expenses:
Banner Health, Phoenix, AZ
CareGroup Healthcare System, Boston, MA
Jefferson Health System, Radnor, PA
Memorial Hermann Healthcare System, Houston, TX
St. Vincent Health, Indianapolis, IN
Medium Health Systems
Between $750 million-$1.5 billion total operating expenses:
Baystate Health, Springfield, MA
Geisinger Health System, Danville, PA
HCA Central and West Texas Division, Austin, TX
Mission Health System, Asheville, NC
Prime Healthcare Services, Ontario, CA
Small Health Systems
Less than $750 million in total operating expenses:
Baptist Health, Montgomery, AL
Maury Regional Healthcare System, Columbia, TN
Poudre Valley Health System, Fort Collins, CO
Saint Joseph Regional Health System, Mishawaka, IN
Tanner Health System, Carrolton, GA
Thomson Reuters says its study looked at eight metrics that gauge clinical quality and efficiency: mortality, medical complications, patient safety, average length of stay, 30-day mortality rate, 30-day readmission rate, adherence to clinical standards of care (evidence-based core measures published by CMS), and HCAHPS patient survey score.
The study found that regardless of their size the top health systems shared many of the same qualities, including:
Lower 30-Day Mortality Rates
The 15 top health systems held post-discharge 30-day mortality rates steady. Peer health systems showed a significant increase in post discharge mortality.
Better Survival Rates
Top hospitals had 17% fewer deaths than expected considering patient severity, while non-winning hospitals had 4% more deaths than expected.
Fewer Complications
Patients of top health systems had 19% fewer complications.
Shorter Hospital Stays
Patients treated in top systems have an average length of stay of 4.7 days, nearly half a day shorter than their peers' median of 5.1 days.
Better Patient Safety and Core Measure Adherence
Top health systems had 23% fewer adverse patient safety events than expected and had better adherence to core measures of care than their peers.
The study used the 2010 Medicare Provider Analysis and Review (MedPAR) and the CMS Hospital Compare data sets to examine health systems with two or more short-term, general, non-federal hospitals; cardiac and orthopedic hospitals; and critical access hospitals.
It seems each new study that examines a particular facet of nursing also reinforces the notion that nurses are the backbone of healthcare delivery in the United States.
Nurses play the leading role in delivering and coordinating care for patients, safeguarding them against medical errors, and acting as the patients' advocate at a time when patients are struggling with anxiety, fear, pain, and confusion.
The role of nurse advocate and care coordinator will only grow in coming years as the practice of medicine gets more complex, and the medical care team approach becomes more entrenched. One could argue that experienced and well-trained nurses at the bedside are as big a factor in determining healthy patient outcomes as any other component in healthcare delivery. Someone will have to lead the care team, and nurses are the obvious choice.
The common sense findings in a Robert Wood Johnson Foundation study this month underscore the importance of nurses' critical thinking skills as the key component in reducing errors and improving outcomes.
Independently reconciling medications with patients' records;
Verifying medications and doses with colleagues;
Coping with interruptions and distractions;
Interpreting physicians' orders;
Documenting near misses;
Communicating openly with physicians, pharmacists and other team members.
This is not breaking news. Everything on that list would prompt a knowing nod from nurses.
However, these findings also give those who aren't nurses a better idea of the challenges that nurses face every day and the skills they need to do their job effectively. Imagine the sum total of these 10 focus points for each patient, multiply it by the number of patients under a nurse's care at just about any time and on no particular floor, and you might have a better idea of the pressures on time that are placed upon nurses on any given 8- or 12-hour shift.
Among the most serious problems nurses continually face are missing medications and the timeliness of medication delivery, the study found. Administering medication seems simple enough until the pressures and distractions that nurses routinely face are factored in.
For example, medication delivery schedules at hospital pharmacies may not jive with nurses' work schedules. Or, the patient may be scheduled for other tests that coincide or interfere with medication times. The INQRI study found that effective strategies to ensure medication compliance included repeated calls to the pharmacy to check on medications' status, marking drugs to be given immediately, and often picking up the medications themselves instead of waiting for delivery.
The study made clear that the ability of nurses to effectively communicate with everyone in the care continuum—from the patient to the subspecialist—is particularly important.
Coauthor Linda Flynn, RN, professor and associate dean for graduate nursing education at Rutgers, said the study "identified communication with doctors, pharmacists and other nurses as an indispensable part of preventing medication errors and ensuring patient safety."
"That means that nurses also (should) take responsibility for developing good relationships with all members of the health care team, so that when they have to locate missing medication, double-check doses or ask questions about new medications, they get the answers they need when they need them," Flynn said.
The study recommends tapping into nurses' clinical reasoning as a foundation for reducing medication errors in the care team environment. Such a program would push nurses to move beyond the "five rights" of medication administration (1. Right patient, 2. Right Route, 3. Right Dose, 4. Right Time, 5. Right medication) and to use clinical reasoning to protect their patients from harm.
The study also calls for retooling provider education to promote the team care approach. That includes learning basic errors theory and team-centered clinical problem-solving exercises.
As the study makes clear, nurses will face a variety of new challenges in the coming years as they are asked to play a greater role in patient care coordination. Everyone else in the healthcare delivery system must understand that role and must be willing to provide nurses with the support and resources they need to do their many jobs.
A new program at Spectrum Health in Grand Rapids, MI is identifying "frequent fliers" at the system's emergency departments and placing those patients with a multi-specialist intervention team.
The program, while only six weeks old, has steered more than 140 patients to the less-expensive coordinated care program and has saved the health system a net total of about $300,000.
"It's going really well—better than we had hoped," says R. Corey Waller, MD, a specialist in addiction and emergency medicine, and director of the Spectrum Health Medical Group Center for Integrative Medicine.
"We are focusing on getting the patients better and not decreasing ED visits, because if you do the one the other will follow," he says.
The program was launched in early December and identified about 950 patients who'd used the emergency rooms at Spectrum's Butterworth and Blodgett hospitals more than 10 times in a year. Those patients accounted for more than 20,000 total visits and up to $50 million in costs annually.
The center randomly contacted about 190 patients, 140 of whom agreed to the coordinated care treatment regimen.
"By the time we get them they are pretty broken and the ones that show up are the ones that want help. What we are seeing right now is going to be a skewed view to the person who is sicker and wants help because they are coming in willfully," Waller says.
"Once we get them into the center they stay because they realize the approach we take is different," he says. "We don't fire them and we tell them straight up we don't care what they are doing that may have irritated other doctors in the past. We just need to know it so we can come together with a plan."
The center's treatment team uses addiction specialists, psychologist, RN case managers, and social workers to confront not only the medical issues—often pain, addiction, or both—that are driving these patients into the ED, but also the psychological and social issues that may be exacerbating the problems.
"Most of these patients don't know what do to. They really want someone to guide them through this," Waller says. "There are times when the RN case manager or social worker is able to guide them better than I do. We work together with each of the patients after we do our intake. Any plan I come up with has to be in line with the psychological side and the social side. We manipulate our plans so they work together and we present that to the patient before we finalize the plan."
Waller says the patients are not chastised nor forced to agree to treatment plans dictated by the medical staff. "We don't have them sign any contracts and that is the big thing," he says. "If you have someone with true pain or who has a true neurobiological addiction who is not being treated they are not going to adhere to some contract because they don't see risk and benefit the same way we do."
The program is expected to grow as more eligible patients learn about it and understand that it's not a trick.
"They're scared. They think it is a bust," Waller says. "When they realize we are trying to get them some help they come back. It's a matter of getting them to trust us. Now we have a core group of patients in the neighborhood saying 'they are here to help you out.'"
As many as 40% of the center's patients are neurobiologically addicted to some substance. Waller says the center has successfully developed a treatment regimen that couples medication with behavioral therapy and modification. "More than 90% have stayed clean since they started treatment here," he says.
The net savings of $300,000 in six weeks and the drop in ED use has attracted the attention of payers, including commercial insurers with Medicaid plans.
"I just want them to pay for an episode of care. 'You give me the money we will get them better.' It is a small amount of money but it helps us to get closer to solvency," Waller says. "This is not a clinic built to make money but to save money. What we are trying to do is make sure that it is a sustainable business model. Right now we have a three-tiered payment system. We get $700 for an easy patient, $1,400 for a medium patient, and $2,100 for a difficult patient. And that covers everything. It saves a ton of money."
The center has kept detailed data on the program.
"The goal is to come up with a screening tool so we can identify them on visit No. 2 to the ED and get them the social or psychological or medical services they need before they turn into high frequency use," he says.
With the implementation of the Affordable Care Act, Waller says Spectrum's model could provide an affordable way to control healthcare costs for that high-usage population.
"One of the biggest issues is how do we create comprehensive care and still pay your bills? If you try to create comprehensive care in every doctor's office you will lose your shirt," he says.
"What needs to happen is a model like this that is more of a specialty place where you filter patients so that everyone who has a questionable issue or multiple issues would come through here and be medically, psychologically and socially evaluated and stabilized."
When that's done, Waller says, the patients can be transferred to a traditional primary care environment. "All they have to do is maintain it," he says, "because it becomes so expensive if every doctor's office has to have a psychologist or a social worker or five RN case managers."
Waller says he wants to show other health systems how to replicate Spectrum's success.
"We are retooling efficiencies right now," he says. "The reality is you have to have appropriate through-put without marginalizing the information we are getting. In two weeks we will have that on paper so we can have the billing codes and the ways it has to be documented set up."
"Within two to three weeks we are going to be able to tell somebody how to replicate this if they would like to."
Medicare Advantage plans that include fitness benefits such as gym memberships attract significantly healthier enrollees who are also less expensive to cover, according to a study in TheNew England Journal of Medicine.
"It makes sense. The people who would value fitness memberships would be healthier and have fewer functional limitations," says Amal N. Trivedi, co-author of the study, Fitness Membership and Favorable Selection in Medicare Advantage Plans. "And that group of seniors that participates in fitness programs has lower health expenses."
The study examined 11 Medicare Advantage plans that offered fitness club memberships against a control group of 11 Medicare Advantage plans that did not offer the benefit. Researchers compiled data from 2002 through 2008 and compared the self-reported health status of the people enrolled in one of the plans before the gym membership was offered, with the self-reported health status of people who enrolled after the benefit was offered.
The proportion of enrollees who reported that they were in excellent or very good health was 6.1 percentage points higher among the 755 new enrollees in plans that added fitness benefits than it was among the 4,097 people who enrolled before the benefit was included, the study found.
Conversely, the proportion of new enrollees who reported physical activity limitations was 10.4 percentage points lower, while the proportion of enrollees who reported problems walking was 8.1 percentage points lower, when compared with the earlier enrollees, the study found.
Within the control plans that did not offer gym memberships, differences between the 1,154 new enrollees and the 3,910 earlier enrollees were only 1.5 percentage points or less for each measure. The adjusted differences between the fitness benefit plans and the control plans were 4.7 percentage points higher for general health, 9.2 percentage points lower for activity limitations, and 7.4 percentage points lower for difficulty walking.
"If you look at the proportion of plans that offered coverage with fitness memberships from 2002 through 2008, there was a fourfold rise from 14 of the plans that had continuous participation in the Medicare over that time period to 58," says Trivedi, a general internist with the Department of Health Services, Policy, and Practice, Alpert Medical School of Brown University, and a researcher with Providence Veterans Affairs Medical Center, Providence, RI.
"If you extrapolate that trend it's probably more likely that even more plans offer coverage with fitness memberships in 2012," Trivedi says. "We were very struck by the tremendous growth in the number of plans that offer gym membership. That suggests to us that this is probably an attractive business proposition for health plans."
While the gym memberships and other wellness benefits are widely seen as a way to improve enrollee health and reduce healthcare costs, Trivedi says that represents a skewering—whether intentional or not—of the intent of the Medicare Advantage program.
"The hope was that plans would compete against each other on the basis of their ability to improve care and reduce costs and not on their ability to attract the healthy and exclude the sick," he says. "We don't know the rationale for why plans offer these memberships, but the effect is that the plans get a healthier slice of the Medicare population."
"There are lots of reasons to offer fitness memberships. It could be to improve the health of existing enrollees or to retain enrollees who value that service," he says. "In general policy makers are uncomfortable with the notion that plans are able to compete on the ability to cherry pick the healthiest enrollees."
Robert Zirkelbach, spokesman for America's Health Insurance Plans, contends that " [one] from a methodological standpoint they are relying on self-reported health status and two they acknowledge that some of the data they are looking at is from before the enhanced risk adjustment of 2004. There is risk adjustment system in place designed to address the adverse selection."
"The broader, more important point," Zirkelbach says, "is that health plans are providing services that beneficiaries want. They are responding to the demands of consumers—particularly at a time when there is broad agreement from across the healthcare system that we need to do more to encourage people to live healthier lifestyles, to get preventative care, and to take better care of their health. Health plans have pioneered the types of programs on the commercial side and in public programs to help patients better manage their health and live healthier lifestyles. That is showing demonstrative results in improved health, better health outcomes, and lower costs."
Trivedi says he hopes the study will make policy makers more aware of the consequences that even relatively small changes in benefit design can have on a program. "To the extent that policy makers want plans to just compete on their ability to provide high quality service to enrollees and reduce costs, that they should be aware that subtle changes in insurance benefits can have big results," he says.
The idea that health insurance companies might be using fitness benefits to cherry pick healthier enrollees has been a subject of speculation in healthcare economics circles for several years but Trivedi says there hadn't been empirical data to back up the idea before his study. "That is what we enjoyed about this study— that we could finally put some numbers to this phenomenon that people have been speculating about for some time," he says.
The union-management animosity at Holy Family Hospital in Methuen, MA, did not end with last July's vote by nurses to join the Massachusetts Nurses Association/National Nurses United.
The National Labor Relations Board has taken up a complaint that a veteran nurse at the hospital was fired last year by Holy Family's parent Steward Health Care Systems, allegedly for her role in the organizing effort. An administrative judge will hear the complaint on Feb. 14.
Steward Health Care Systems denies the allegation and has issued a statement saying that "participation in union organizing activities played no role in the decision" to fire nurse Mary Ramirez, 61, who'd been at the Holy Family for 18 years.
These two narratives could not be farther apart. MNA/NNU calls Ramirez a martyr for the cause. Steward alleges that Ramirez endangered the life of a patient and slyly hints that she may have had a drug problem.
Steward says Ramirez was fired "because she intentionally changed a doctor's orders, committed an intentional medical error, and failed to enter the fact that she administered a powerful narcotic (morphine) into a patient's medical record. Ms. Ramirez admitted these facts to a fellow nurse, who then reported her actions to management."
Steward went on to claim that Ramirez's "intentional change to a doctor's orders, falsification of a medical record, and attempted cover up, combined with the fact that she had been previously placed on probation for two years by the Board of Registration in Nursing for diverting patient medication for her personal use, were the reasons for her termination." Along with terminating her employment, Steward also reported her actions to the Board of Registration in Nursing.
The fight has gotten so ugly that the two sides can't even agree on a name. MNA/NNU refers to Steward Health Care Systems as Cerberus-Steward Health Care to draw attention to the private equity firm that has bought 10 Massachusetts hospitals in the last 18 months.
The fight at Holy Family has become so toxic, and this is seven months after the union vote, that it is easy to forget that this is a hospital and not a tire factory or a rendering plant.
Probable Consequences
How will all of this play out? If it's anything like labor disputes at other hospitals, at some point the two sides will come to an agreement and some sense of normalcy will return to Holy Family. They'll issue media statements about working together to create a healing environment for the good of the community, let bygones be bygones, blah, blah, blah.
It is still worth asking about the long-term effects. Regardless of what an administrative law judge determines next month on the NLRB complaint (which either way will almost assuredly prompt an appeal by the losing side), scars will remain and public doubts, quite deservedly, will linger.
After reading the charges and counter-charges issued by Steward and the union—regardless of their validity—why would anyone in Methuen, MA, seek medical care at Holy Family Hospital?
Again: Based on what the two sides are saying about one another, the public in Methuen would be within bounds to see management as greedy and vindictive, and staff as angry, reckless and incompetent.
For that matter, at a time when skilled healthcare professionals are at a premium, why would any physician, nurse, or administrator take a job at Holy Family knowing they would be entering a volatile environment that is hardly conducive to healing or congeniality?
Unfortunately, the acrimony at Holy Family may be a harbinger. As the fight for diminishing healthcare dollars intensifies in the coming years, it would not be surprising to expect more labor strife in hospitals across the nation.
With less money, management will be less inclined, or able, to negotiate as margins shrink. Staffing and scheduling issues, compensation cuts, and quality of care challenges will create resentment and fear in the healthcare workforce, making the call to organize all the more appealing. Sophisticated, battle-tested healthcare labor unions such as the NNU will tap into that worker angst and enjoy even more success.
It is not hard to foresee the healthcare landscape broken into entrenched and polarized camps, with labor and management snarling at one another across a no-man's land. Caught in the middle will be the patients hoping to dodge the crossfire.
Healthcare continues to lead the nation in job growth, accounting for nearly for nearly one in five new jobs in the overall economy, Bureau of Labor Statistics data shows. Hospitals created 9,800 new jobs in December, and 89,100 jobs in 2011, finishing a strong year for job growth that saw 314,700 payroll additions in 2011. Here are some notable executive moves this week:
Healthcare created 22,600 jobs in December, finishing a strong year for job growth that saw 314,700 payroll additions in 2011. Healthcare accounted for nearly one in five new jobs in the overall economy, Bureau of Labor Statistics data shows.
Hospitals created 9,800 new jobs in December, and 89,100 jobs in 2011, more than double the 37,300 jobs hospitals created in 2010.
"Last year, 2011, was a very good year for St. Luke's Health System. It's going to be more of the same in 2012," said Dawn Murphy, senior vice president – human resources, with the 10-hospital St. Luke's Health System in Kansas City, MO, which has 9,500 employees.
"We are adding staff, particularly nurses, because of our facilities' expanding. We have seen volume increases and that have stimulated our hiring," Murphy said. "We are also an attractive employer and that has always helped us. People want to work here. We received over 100,000 applications for employment last year and we filled 2,000 positions."
Chris Roederer, senior vice president, human resources, at Tampa General Hospital, says the safety-net hospital saw some incremental job growth in 2011. External pressures, however, including a $20 million Medicaid funding cut from the state of Florida, have created a challenging fiscal environment that will impact hiring.
"It is going to be one of the more difficult years in our history, and we don't expect it to get easier. The pressure is going to continue," he said. "It's very unfortunate. We worked hard to get the reputation we have," Roederer said.
Roederer says TGH has targeted two areas for new jobs. "One has been positions related to the implementation and optimization of our electronic health records. Our IT area has grown substantially to meet that need," he says. "Another area has been in ambulatory services, our primary care centers, and even the employment of physicians."
"It has been reasonably difficult to fill positions but we are getting there," he Roederer explained. "There is substantial competition for primary care physicians and I expect that to be difficult in years to come as hospitals build their primary care networks."
"The IT positions with hospitals, the demand for that specialty and recruiting and retaining those people is going to be even more difficult. They are so specialized and in such high demand. We are finding that already," he said.
Murphy says the search for clinicians with IT competency will remain a challenge in 2012, especially with the coming of meaningful use requirements, and the upgraded ICD-10 medical coding.
"The IT department is always in search of the person who has the combination of clinical and IT skills with all that is going on with healthcare reform," she says. "That has been a focus for us over the past year: to recruit clinical people internally if they are interested in IT, and externally the people who have that magical combination of a clinical background with IT expertise."
"They are hard to find, which is why we try to grow our own when we can. For those of us looking outside the people with advanced skills in that area, it's a finite pool and we are competing for the same pool," she said.
Ambulatory services, which include physicians' offices, accounted for 59% of the job growth in healthcare. The subsector created 11,300 jobs in December and 187,000 jobs in 2011, after creating 166,100 jobs in 2010.
Physicians' offices created 19,000 new jobs in December and 67,600 new jobs in 2011, a near tripling of the 25,300 jobs created in physicians' offices in 2010.
BLS data from November and December are preliminary and may be revised considerably in the coming months.
More than 14.2 million people worked in the healthcare sector at the end of 2011, with nearly 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.
The 314,700 jobs created by healthcare represent 19% of the 1.6 million jobs created in the overall economy in 2011.
While there is nothing to indicate that healthcare job growth will slow in 2012, Murphy offered some caveats.
"With healthcare reform it is going to be incumbent upon all of us to be cost efficient," she said. "That is what we are looking at the next couple of years: How can we operate as efficiently as possible? Our reimbursements are going to be lower for the same care. The external pressures are on us to be cost effective. Even if we have a stable workforce, we have cost pressures."
In the larger economy, the nation's unemployment rate dropped from 8.6% to 8.5%—down 0.6% since August, and its lowest level since March 2009. BLS said the 200,000 new jobs created in December came from the healthcare, manufacturing, retail, mining, and transportation sectors.
Nonetheless, 13.1 million people were unemployed in December. The number of long-term unemployed, defined as those who have been jobless for 27 weeks or longer, was little changed at 5.6 million in December, and represented 42.5% of the unemployed.
The American College of Physicians this week issued a sixth edition of its ethics manual, the first rewrite since 2005.
The revised manual, published in ACP's flagship Annals of Internal Medicine, offers new guidance on longstanding issues such as end-of-life care, physician-industry relations, and ethics in medical research.
The manual also tackles emerging issues such as the role of social media and its impact on the physician-patient relationship, the growth and impact of the physician-employee model, treating celebrities in the age of Twitter, and physicians' dual role of serving patients' needs while also marshalling scarce or expensive healthcare resources.
"We're always facing challenging ethical issues," ACP President Virginia L. Hood, MBBS, told HealthLeaders Media.
"The common thread is to do what's in the best interests of the patient."
Hood, who also teaches at the University of Vermont College of Medicine in Burlington, says the growth of social media such as Twitter and Facebook has created potentially huge ethical sinkholes for physicians who don't use them correctly.
"The boundaries may be blurred as physicians and patients interact more via social media, which is really the public domain," Hood says. "People use these in a private way and in a professional way, and it is important for physicians to recognize that and don't let the ease of using these social media create problems with the patient physician relationship or the profession itself. We have to make sure our professional demeanor is maintained whenever we are in the public eye."
Hood says the growth in the physician-employee model may resolve some ethical issues while raising new challenges.
"It goes both ways," she says. "As people are employed and paid in a lump sum for a job they do, it may take away some of the incentives that the current payment system has to encourage more procedures than maybe are necessary. All of the incentives in the system support volume rather than value. Having people employed may take away some of those incentives."
"On the other hand it brings up other issues, such as the institution making demands on how physicians treat patients or what tests or medications they are allowed to use, or pressures to get people out of the hospital sooner because it's better for the institution's bottom line," she says. "There are institutional pressures that can be pressed on employed physicians that we have to be concerned about. It is a growing trend and there might be more about that depending upon how healthcare is paid for."
As medical resources become more expensive or scarce, Hood says physicians may find themselves caught between the demands of patients and the greater society.
"The ethics of professionalism revolve around doing good, doing no harm, allowing patient autonomy and social justice—the equitable distribution of limited resources so everybody has the same chance to get what is needed," Hood says. "These are the principles one has to balance and the decision to do things that may cost more when you can do something that costs less just because a patient saw something on television. We are obligated as physicians not just to try to make the right decisions but to help patients make the right decisions."
