A consumer advocacy group is calling for full and unfettered public access to the National Practitioner Data Base to help patients identify problem doctors in their states.
The Consumers Union's Safe Patient Project said new restrictions imposed on the database last week by the Department of Health and Human Services would protect the identities of problem doctors at the expense of patients.
"When information held by the government is declared 'public' there should be no strings attached to the use of that data," Lisa McGiffert, director of the Safe Patient Project, said in a media release. "The elephant in the room during this whole controversy is that most of this information is public in other places and should be public at the NPDB. It's time to provide the public full access to this critical information, including the names of doctors who have been disciplined by state licensing boards or sued for failing to provide safe care."
The Safe Patient Project demand puts them at odds with the American Medical Association. In a September 23 letter to HHS, AMA CEO James L. Madara, MD, said the nation's largest physician organization has "long opposed public access to the NPDB" because it "was designed for a limited purpose and is not a reliable source of public information about the overall qualifications of physicians."
"Providing the public with unreliable or misleading information on physicians may cause patients to make ill-informed decisions about their healthcare," Madara said in the letter. "Further, we believe that the posting of the public use data file is statutorily prohibited. The NPDB statute explicitly provides that information reported to the NPDB is considered confidential and should not be disclosed except with respect to professional review activity."
Glen R. Stream, MD, president of the American Academy of Family Physicians, is ambivalent about access to the database.
"In general our academy is very patient-focused in our advocacy for how our healthcare system should be structured. Having informed patients making informed decisions about their physicians and other providers is important," Stream told HealthLeaders Media. "One of the concerns physicians have is that if you create a data repository for an original purpose and try to extend it for other purposes, then it may or may not meet that other need." Stream says the database was originally designed for the credentialing process for hospitals, health insurers, medical groups, and state licensing agencies. "To repurpose that information to be the transparent view for patients, I don't know how accessible things are."
"The same issues apply when we talk about patient access to their health information," Stream says. "We very much support that. Yet the structure and vocabulary and the meaning of some of that information is difficult for someone without a medical background."
The battle over public access to the database has see-sawed in recent weeks. In September, HHS removed the database from public view after it received complaints from a doctor whose malpractice history was detailed in a newspaper article. Then, last week, HHS restored the database to public scrutiny but included provisions that shield physicians' identities.
Stream says the lay public often doesn't have the experience or expertise to comprehend much of what is contained in the database. Taking an example from his own practice in Spokane, WA, Stream says a patient read about a physician in the Washington state database and raised concerns that the physician's medical license would soon expire. "The patient thought that was meaningful, when in fact your medical license is not unlike your driver's license. You need to renew it," Stream says. "She read into it that this person's ability to practice medicine was going to expire in the next few months."
Stream says that any physician database must include explanations for the public. "It needs to be created with a user-friendly interface and with some sort of key or dictionary or vocabulary guidance for how to interpret the data. To my knowledge, the National Practitioner Data Base does not contain that."
There isn't much good news in the latest nationwide survey of workplace violence against emergency department nurses. Despite the media attention generated by the 2009 survey, which showed that emergency nurses rank with cops and prison guards when it comes to on-the-job verbal and physical abuse, and the needle hasn't moved in the last two years.
The latest results from the ongoing Emergency Department Violence Surveillance Study of 7,169 emergency nurses nationwide found that 53% of nurses reported experiencing verbal abuse and 13% reported experiencing physical violence over any seven-day period in 2010. Those results are almost identical to those in the 2009 survey.
"The only thing good I see coming out of this is that we continue to let people know that this is an issue. Public awareness is important because it's the public who is committing the violence," says AnnMarie Papa, RN, president of the Emergency Nurses Association, which compiles the survey and report.
What's frustrating is that although the number of zero -tolerance policies is up, Papa says, "the violence in those facilities with zero-tolerance policies is just a little down from what it was the two years ago when we last did the study."
Here are some other notable findings:
Of all the nurses surveyed who indicated experiencing physical assault, 48% said they were grabbed or pulled.
The most common forms of verbal abuse were yelling or swearing, with 89% of nurses reporting those forms of abuse.
Patients committed 98% of the physical violence and 92% of the verbal abuse.
The patient's room was the most dangerous place for an emergency nurse, with 82% of physical assaults occurring there.
More than half —56% —of patients who physically assaulted nurses were drunk, 47% were on drugs, and 45% were psychiatric patients.
What is more troubling, however, is that 66% of nurses did not file a formal report when they were physically assaulted, and 86% did not file a formal report when they were verbally abused.
That means the perpetrator went unpunished. Most nurses did not even notify security personnel, their immediate supervisors, or physicians. I guess the good news is that most nurses didn't just keep the abuse to themselves—they told someone. Only 8% of nurses who were physically assaulted and 17% of nurses who were verbally abused did not tell anyone.
"The people who didn't report it said it was too cumbersome and too time-consuming," Papa says. "Organizations have to look at their reporting mechanisms and see what they can do to streamline it. Can they partner with security in their organization to have that help?"
No matter how time-consuming or burdensome, nurses have to take a greater responsibility to formally report violence, if not for themselves then for their colleagues, who are also potential victims. Also, even thorough and widely drawn surveys like the ENA's are essentially anecdotal. Tackling this issue will require hard data, and nurses are hurting the effort when they don't report the violence.
"We are working hard to make this happen because these zero tolerance policies require nurses and other healthcare workers to report the violence and that is not happening consistently," Papa says. "If the nurses aren't reporting it then we can't trend it. It becomes anecdotal data. But if they are reporting it in realtime we will have some real numbers."
It gets worse. The study found that in 47% of the cases of physical violence, no action was taken against the perpetrator. In other words, they got away with assault once. So, they'll probably do it again.
And, worst of all, in 72% of cases, nurses received no response from hospital leadership about the assault. This is astonishing and utterly inexcusable. How can senior leadership in any organization—from a hospital to a tire plant—not make a personal and immediate inquiry into the health and well-being of an employee who was assaulted on the job? If this is the policy at your hospital, change it.
Ignoring injured employees will make senior leadership appear callous and indifferent, and that would be correct.
"The key for senior administrators to recognize is the high-level buy-in, and the high-level visibility," Papa says. It's not just the name on a piece of paper and a note. It's that personal phone call and personally reaching out. "That call alone makes the nurse or the healthcare worker feel valued, knowing that leadership is watching this, and they are working to make changes."
It's also a dumb business practice to ignore the plight of injured employees in this era of high employee turnover and widespread labor shortages, especially for nurses. The survey found that 37% of emergency nurses have considered leaving their job because of the violence.
Here are two points we can take away from this survey: First, nurses must make a formal report when they are the victims of assault, especially physical assaults. If they don't report it, it will happen again to someone else, perhaps a colleague. Secondly, leadership needs to reach out to any employees who are the victims of assault.
The incessant beeping, chirping, whirring, flashing and whooping of any number of patient monitors continues to be a top hazard in hospitals, as bedside providers either struggle to prioritize the noisy demands of the machines, or tune them out completely.
That's according to a study, Top 10 Health Technology Hazards for 2012, from the nonprofit ECRI Institute. The organization is designated an Evidence-Based Practice Center by the U.S. Agency for Healthcare Research and Quality.
The report notes that bedside providers increasingly are showing signs of "alarm fatigue" as they deal with the constant demands of ventilators, infusion pumps, physiologic monitors, dialysis units, and other technology.
Repeated exposure to the alarms, the report says, can desensitize providers, which can lead to missed alarms or delayed responses, or a failure to make distinctions between the levels of urgency. In addition, the report suggests that some providers improperly adjust monitors to limit alarms, or simply turn down the volume so that the alarms can no longer be heard.
Among its recommendations, ECRI says that healthcare providers should establish institution-wide alarm management programs that examine all equipment being used, and establish protocols for alarm-system settings and notifications.
ECRI's annual report ranks hazards by the harmful impact they could have on patients, how often the hazards occur, how widespread the hazards appear to be, and whether or not the hazards are considered "high-profile" problems that have been covered in the news media, or that providers are pressured to correct.
Here's a brief synopsis of the remaining Top 10 Healthcare Technology Hazards for 2012.
2. Exposure hazards from radiation therapyand CT scans
Radiation exposure, the top healthcare technology hazard in 2011, continues to be a top threat to patient safety. "It isn't clear how many patients are affected by radiation therapy errors – for one thing, there isn't an unambiguous definition of a reportable event – and there is a good chance that incidents are being significantly underreported," the report warns.
With CT scans, the report notes, higher dose levels improve image quality which creates "a natural tendency to use higher doses." In addition, most healthcare facilities do not audit CT doses, so there is a wide variation in the dosages used for the same treatments.
ECRI says there are no simple solutions to correcting the problem, but they recommended in general terms that healthcare providers: ensure proper staffing; install and verify quality control measures; and acquire national accreditation for their radiology an CT services.
3. Medication administration errors using infusion pumps.
While infusion pump technology has improved over the years with the introduction of "smart" pumps, preventable errors continue to occur, and the entire infusion process should be examined, the report says.
Typical problems include illegible orders, incorrectly prepared drugs and solutions, and medication given to the wrong patient. ECRI recommends that providers consider infusion pumps as part of the overall medication delivery system, and determine the compatibility with other safety systems already in place.
Providers should develop drug libraries for clinical areas that use infusion pumps to create standardized concentrations of commonly used drugs and solutions, ECRI recommends.
4. Cross-contamination from flexible endoscopes
The report notes that when endoscope reprocessing problems surface, they can create great anxiety among patients who are told that they may have been exposed, and they can be highly damaging to a healthcare facility's reputation. "At worst, they can lead to life-threatening infections. Such incidents are almost always associated either with failure to follow established cleaning and disinfection/sterilization guidelines and instructions, or with the use of damaged or malfunctioning equipment," the report says.
"Flexible endoscope reprocessing requires consistent adherence to a multi-step procedure. Failure to properly perform any step, including some necessary manual tasks, could compromise the integrity of the process."
ECRI recommends that healthcare facilities; have strict and detailed reprocessing protocols for every model of flexible endoscope in their inventory; periodically review those protocols; and make sure the protocols are readily available to employees who are responsible for the reprocessing.
5. Inattention to change management for medical device connectivity
Problems are arising with the growing interrelationship between medical technology and IT, and the potential for incompatibility. "A key reason problems arise is the failure to implement adequate change management policies and procedures that accommodate both IT and medical technology needs," the report says.
"Because medical devices and health IT are becoming so interconnected, healthcare facilities must be aware of a possible domino effect wherein changes to one component of the system affect the operation of another." ECRI recommends that healthcare facilities evaluate policies and procedures around change management to ensure that issues around healthcare IT and convergence are addressed, with particular care taken to determine how technology decisions involving medical devises and IT networks can impact operations and patient care.
6. Enteral feeding misconnections
Misconnections usually take one of two forms: nutrients intended for the gastrointestinal tract are delivered elsewhere; and inappropriate fluids are delivered to the GI tract. The first problem is the more serious because it can result in death by embolism or sepsis, the report said.
ECRI recommends that enteral pumps be used for enteral feeding only, and that color-coded feeding lines and connectors be traced from end to end when making initial connections. The report also recommends that the standard Luer syringe never be used for oral medications or enteral feedings, and that IV or feeding devices never be adapted for other purposes.
7. Surgical fires
ECRI said it continues to receive reports of one or two surgical fires each week, and the institute estimates that there are about 600 surgical fires each year nationally. "Not all surgical fires result in patient injury, but when they do, the consequences can be severe, including potentially fatal airway burns and horrible facial disfigurement," the report says.
"Virtually all surgical fires can be avoided. But doing so requires that each member of the surgical team clearly understands the role played by oxidizers, ignition sources, and fuels in the operating room." ECRI recommends that hospitals implement surgical fire prevention and management programs; that include familiarization with risks posed by oxygen-enriched air.
The report also recommends discontinuing the traditional practice of open delivery of 100% oxygen during head, face, neck, and upper chest surgery.
8. Needlesticks and other sharps injuries
Needlesticks and other sharps injuries continue to pose a threat of exposing healthcare workers to bloodborne pathogens such as HIV and hepatitis. "Most hospitals have ongoing programs to address sharps safety. But these programs may have been established some time ago and may no longer be receiving adequate attention or achieving their expected level of effectiveness," the report says.
"Continuing injuries are a signal that additional attention is needed; it could be that clinicians are using poor technique, that the safety devices being used should be replaced with more effective models, or that gaps exist in the facility's sharps safety program."
ECRI recommends that healthcare facilities; conduct annual reviews of their sharps safety programs that include assessments of injuries and current practices; and develop action plans that identify and categorize injuries and include remediation plans.
9. Anesthesia hazards due to incomplete pre-use inspection
The report notes that thorough pre-use inspection of anesthesia units has long been accepted as standard procedure. "However, in actual practice, such inspections can be inconsistent and incomplete. Hospital staff sometimes conducts pre-use checks using obsolete procedures or procedures designed for anesthesia units other than the one being used."
Staff may also skip some parts of the inspection because they don't understand its importance or mistakenly believe that the step is being performed by another person, or the unit's semi-automated self-check. ECRI recommends that full inspections of anesthesia units be undertaken every day before the first case of the day, and that subsequent checks throughout the day include the manufacture's prescribed abbreviated check for that model anesthesia unit.
ECRI also recommends that facility policy should clearly state which staff members are responsible for performing the checks, that the check list be readily available to staff, that the findings are documented, and that the checks are expanded to include airway suctioning equipment and manual resuscitators.
10. Poor usability of home-sue medical devices
More people are receiving care in their homes. That limits supervision of caregivers and equipment. "Often, devices that are used in the home are not designed with the lay user in mind," the report says. "They are frequently very difficult to use or very complex, and in fact may sometimes be identical to devices used in the hospital by clinicians."
ECRI recommends that homebound patients, their families, and their caregivers first be evaluated to determine their technical competency before prescribing medical equipment for the home. ECRI also recommends that patients and their families be given educational materials about their medical equipment, and contact information with the provider should problems arise.
Just-in-time scheduling can often mandate when employees will work, when they'll work overtime, and when they'll be sent home with little notice for any contingency—all of which is designed to save money by more closely linking labor with immediate demand.
One human resources expert says, however, that a poorly designed just-in-time scheduling system will do exactly the opposite and will end up costing healthcare providers more money in higher absenteeism and turnover.
"I'm not arguing that it should be eliminated. I'm arguing for effective scheduling," says Joan C. Williams, founding director of the Center for WorkLife Law. "Just-in-time scheduling is a fact of life. Designing it efficiently is a business imperative."
Williams says there is "a big difference" between flexible scheduling and just-in-time scheduling, and to a degree it is dependent on the class of workers. "Flexible scheduling is generally used to refer to professionals and indicates that they are allowed to do something more flexible than just come to work and stay until the work is done, which is often more than eight hours a day," she says.
"Just-in-time scheduling refers to hourly workers, most often low-income workers. That refers to a scheduling system that attempts to control labor costs by achieving a tight fit between labor supply and demand. To do that, the employees typically have schedules that change from day to day and week to week. Often, they have no guarantee of any given number of hours."
In a hospital setting, "one of the persistent examples that [is] given in just-in-time scheduling is nurses' aides who show up for a shift and find that the patient census is lower than expected, so they are sent home without the hours," Williams says. "Or people are ordered to stay overtime with no notice. Mandatory overtime is sometimes necessary. We have to deliver the services as employers. The question is how do you design the mandatory overtime system again to achieve that tight fit?"
Matching the Workplace to the Workforce
It is exactly that rigid format that will drive workers to quit, often because personal commitments such as child- or elder-care make uncertain scheduling impossible to work around. "I'm asking employers to match today's workplace to today's workforce," she says.
"Rather than making believe we have the breadwinner homemaker workforce of 30 years ago, because we don't. We have a workforce where many of the men and women have really pressing important and non-negotiable family care requirements."
"If employers try to pretend they don't exist, they are going to have extremely high absenteeism as people call in sick because they have no alternatives, or extremely high turnover," she says. "The message for every employer is: 'If you want to decrease absenteeism and drive down turnover you have to match today's workplace with today's workforce.'"
3 Steps to Better Labor Scheduling
Williams offers a three-step approach to building an effective scheduling platform that relies on transparency and flexibility:
"A very simple step is to go from mandatory to voluntary overtime," she says. "That is important because some people want overtime and others can't show up because they are tag-teaming or they are single mothers."
"Use one of two methods to handle the situation, if after shifting to voluntary overtime, you still need people to work," she says. "Some employers give employees coupons or vouchers that allow you to bid for more overtime or to bid off overtime. The second system is to divide your workforce into four groups, one of which will be on call in week one of every month, the second group for week two, etc. That way people can find back-up if they are called in to overtime at short notice."
"The third overriding principle is to work hard to design a system where people get notice of overtime to the maximum extent possible," she says.
Fortunately, Williams says, the advent of cloud-based computing is making online scheduling affordable and available to most every provider, often for as little as $1.25 per employee per month. That is actually cost effective, she says, because it eliminates the cost of the scores of hours that supervisors spend each month devising schedules.
A small community hospital can shift to online scheduling and see immediate positive results. "It allows you in a very time-efficient way to register what are those times when your given employees can't work because they don't have child care or grandma needs to go to dialysis. You plug those in," Williams says.
"The second step is to arrange for an efficient shift swapping system that can all be done on line. The third step is to arrange for mandatory overtime. For example, using the coupons we talked about so you can efficiently staff overtime."
Mandatory overtime is a fact of life in most hospitals, Williams says. But employees will be much more willing to comply with the mandate if they understand the process. "The literature shows that if properly implemented, it is going to drive labor costs down sharply because it will drive down absenteeism and drive down attrition," she says. "The main point is I am not asking employers to be do-gooders. I am asking them to design one of their major business systems in an effective way."
For the second time in four years, a jury has handed a Boise, ID radiologists' group a multimillion-dollar award in its suit against one-time partner Saint Alphonsus Regional Medical Center.
The complaint by MRI Associates alleged that Saint Alphonsus conspired with a rival imaging group to steer business away from MRI Associates, even though it was partners with the hospital.
Last week, a 12-member jury needed only one day of deliberations after an eight-week trial before it awarded MRI Associates $52 million, which plaintiffs' attorney Wade Woodard says represents the value of the income lost when Saint Alphonsus drove business to rival startup Intermountain Medical Imaging.
"This case was all about money, profits," Wade Woodard, a principal Banducci Woodard Schwartzman PLLC, a Boise-based litigation law firm, told HealthLeaders Media. "Saint Alphonsus went from having about a 27% interest in all the MRI scans that were done to a 50% interest."
MRI Associates was founded in 1985 as a partnership among physicians, radiologists, and several hospitals, including Saint Alphonsus. In about 2000, however, radiologists at the hospital started their own practice, Intermountain Medical Imaging.
Woodard says Saint Alphonsus took an active role in establishing Intermountain and worked to drive business toward the rival practice, even as it was in an active partnership with MRI Associates. Woodard says the hospital acted in bad faith and reneged on a no-compete promise with MRI Associates, which he says has lost about $25 million in value since 2005.
"St. Al's, while it was in a partnership, competed against that partnership. That is against the law. The jury saw that," Woodard says. "St. Al's should have told the radiologists 'whatever you guys do, we are sticking by our partners.'"
In 2007, during the first trial, a jury awarded MRI Associates $63.5 million – the largest jury award in Idaho history. However, that award was reduced by a judge to $36 million, and the verdict was reversed by the state supreme court and sent back to the lower court for retrial.
Last week's $52 million award represents the second-largest jury award in Idaho history.
Woodard says he anticipates that Saint Alphonsus – which is affiliated with Trinity Health – will appeal the latest verdict as well. "We are hopeful that it will stand up. The judge ran a clean trial and there is no reason why it shouldn't stand up on appeal," he says.
Elizabeth C. Duncan, director of public relations for Saint Alphonsus, said in an email response to HealthLeaders Media that the health system is considering its options.
"Saint Alphonsus is studying our grounds for appeal of the jury verdict and believes that there are a number of substantial issues for consideration by the Idaho Supreme Court," she says. "The timing and amount of any payment by Saint Alphonsus will depend on the outcome of the appellate process and any further proceedings, which at a minimum would take many months."
"Saint Alphonsus mission of providing superior quality care to serve the community is at the forefront of every decision it makes, including those made in connection with this matter. Saint Alphonsus declines further comment at this time, as the matter remains in active litigation.
Woodard says the suit should serve as a cautionary tale to other hospitals. "If you're in a partnership, be true to that partnership," he said.
Last week, I cited a new study suggesting that high employee turnover in hospitals could be linked to low funding of healthcare human resources departments, as compared with industry averages.
It was a fair critique, and there has been lots of commentary of late about the need for hospitals to improve retention, especially among younger nurses.
On a related issue, however, many hospitals do exceedingly well: retaining older workers. That point was brought home in an AARP report in September that placed 18 hospitals among the nation's Top 50 "Best Employers for Workers Over 50."
It shouldn't be surprising that hospitals dominate the list. Some professions—such as journalism—regard older workers as expensive, hidebound, and slow-moving wildebeests that are easy pickings for layoffs when they begin to straggle behind the herd.
Hospital HR leaders, however, recognize the value of their senior staffers, who carry in their skulls a lifetime of institutional wisdom and real-life experience. Hospital HR leaders also understand the skyrocketing costs of recruiting and retaining older staffers' replacements when a nationwide workforce shortage means qualified candidates are holding most of the cards.
I spoke with HR executives at two health systems that made the AARP list: Bonnie Shelor, senior vice president of human resources at Richmond, VA–based Bon Secours Richmond Health System; and Sid Seligman, senior vice president for HR at West Orange, NJ–based Saint Barnabas Health Care System. When it comes to retaining older staff, Shelor and Seligman are singing in the same choir.
"We put a premium on older employees," Shelor says. "In our organization we greatly value the kind of knowledge and experience and intellectual capital and wisdom that the older worker brings to us. You just can't replicate it. We see the older worker is a great mentor/guide/coach for the younger worker. A pairing of those two is the best of all worlds."
Seligman says: "We look at the needs of all of our demographic, especially staff over 50, because we are heading to an organization with an average age in that area, around 47 years old. We want them to believe that if our leaders are attuned to the needs of their staff and support them adequately, the staff, in turn, will be engaged in the mission as we like to see it executed."
Let's concede that the stalled economy has played a role in lower turnover of senior staff at many hospitals. Bluntly stated, many people can no longer afford to retire, or they may be supporting a family member who's lost a job.
But that isn't the only explanation. Seligman and Shelor say hospitals do a better job retaining senior staff because hospitals have been practicing for longer than most other industries. And one of the first things they recognized that seniors want is flexible scheduling. "Healthcare lends itself to flexibility," Shelor says.
"We are open 24/7 and there are many different roles for healthcare workers, nurses in particular. It is not a cookie cutter job."
Shelor says Bon Secours designs career paths for its staff that will allow them to remain working for the health system for their entire career. "When nurses come into our organization, if they come in right out of school, what we tell them is they can have a job with us for life through the many stages of their own lives," she says.
"That would be as a young person, a young mother, a mother of teenagers, as a daughter of aging parents. The needs of workers change in their lifespan, and healthcare is uniquely designed to respond to those needs because of the 24/7 platform and the ability to be flexible."
Both Saint Barnabas and Bon Secours also allow senior staff to keep their health insurance plans even as they reduce hours. "We offer a program where people can work part-time, get full-time benefits, and when the census spikes they are the first people we go to put in additional hours. It's a way for people to phase into retirement," Seligman says.
As workers grow older, Seligman says, the physical demands of the job become even more challenging. Nurses are sometimes on their feet for 12 hours. "The desire to retire is there, although the fear that one is unable to retire is there and we try to deal with those concerns as well with financial planning," he says.
Every day about 10,000 baby boomers turn 65. What does that portend for the future of the workforce across all industries? We often hear about what healthcare HR can learn from other industries. When the topic is retaining older workers, however, Shelor says other industries need to learn from healthcare HR.
"Healthcare HR was on the forefront because of a definitive need early, and that is the shortage of nurses. But every industry needs to take advantage and promote and support older workers," she says.
"Other industries, if they have not, need to wake up and realize that they have to respond with flexibility to the needs of the older workers," Shelor says. "Not only are they able to keep workers in the workforce and reduce their vacancy rate, also, they get the advantage of the wisdom and history that older workers have."
Healthcare created 11,600 jobs in October—a significant drop from the 45,000 jobs created by the sector in September.
However, even with the decline, healthcare remains a leading source of job creation in the overall economy, and was responsible for 15% of the 80,000 new jobs across all sectors in October, new data from the Bureau of Labor Statistics show.
Through the first 10 months of 2011, healthcare created 266,000 jobs—more than the 263,400 healthcare jobs created in all of 2010. Healthcare is on a pace to create 319,000 new jobs by year's end. So far this year, the 266,000 new healthcare jobs represent 22% of the more than 1.2 million non-farm jobs created in 2011.
While the job growth is heartening within the healthcare sector, and it is providing some short-term good news for an otherwise dire job market, some observers say it's not necessary a healthy trend.
"It's probably a bad thing. It's definitely not sustainable for the long term," says healthcare economist Jason Shafrin. "Let's say that healthcare worked perfectly and you could cure someone with one pill that cost $1. That would be a very efficient use of healthcare and people would spend all their money and effort on things that would be more useful."
Healthcare in America is highly inefficient and expensive, however. "It's providing a service that is needed, but it is not so clear that an increase in spending is good," Shafrin says. "It does employ people. But in bad neighborhoods they employ a lot of police, and you would prefer not to have that."
Labor represents about 60% of healthcare costs, and the salaries paid to healthcare workers take money from other areas of the economy. At some point, the demand for new healthcare workers will collide with consumers' inability to pay for care, Shafrin says. "Something will have to happen. The cost pressures are too strong. It's like the housing sector. You can see it growing and growing and growing and eventually there has to be a self-correction."
The 70,100 new hospital jobs so far in 2011 are nearly three times more than the 23,400 new hospital jobs reported in the first 10 months of 2010. However, this year's explosive growth tapered somewhat in October with hospitals reporting 3,300 new jobs, a significant drop from the 13,300 new hospital jobs in September, BLS data show.
Ambulatory services—which in recent years have been the biggest job-growth source in the overall economy—also saw a significant slowdown in October. This sector, which includes physicians' offices, created 4,800 new jobs in October after reporting 26,000 new jobs in September and 18,100 new jobs in August. Ambulatory services have been responsible for 58% (155,200) of new jobs in healthcare so far in 2011. In the first 10 months of 2010, ambulatory services created 148,200 new jobs.
Physicians' offices alone have created 62,000 new jobs in the first 10 months of 2011, compared with 25,300 jobs created in that subsector for all of 2010. Physicians' offices created 8,200 jobs in October, after posting 12,200 new jobs in September. Physicians' offices created 23,100 new jobs in the first 10 months of 2010.
BLS data from September and October are preliminary and may be revised considerably in the coming months.
More than 14.1 million people worked in the healthcare sector in October, with more than 4.7 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 the larger economy, nonfarm job growth was up slightly in October, with 80,000 payroll additions reported. Overall, the nation's unemployment rate remained unchanged at 9%—its level since April—with 14 million people unemployed. The number of long-term unemployed, defined as people jobless for 27 weeks or longer, was 5.9 million in October, down from 6.3 million in September, and represented 42.4% of the unemployed.
After a decade of documenting, Highmark, one of the nation's largest Blue Cross and Blue Shield affiliates, says physicians and hospitals in its Quality BLUEpay-for-performance initiatives consistently outperform providers who are not part of the program.
In its annual report for fiscal 2011, Highmark says Quality BLUE has used financial incentives to lower healthcare-acquired infection rates—saving hundreds of lives and tens of millions of dollars—and improve screening rates and overall patient safety. The quality measures continue to improve even as the program has grown to include 1.7 million Highmark members, 81 hospitals, and 1,600 practices in 49 counties in central and western Pennsylvania.
Deb Donovan, director of provider performance and strategy at Pittsburgh-based Highmark, told HealthLeaders Media that the secret to the PFP model is simple.
"Frankly, it is skin in the game," Donovan says. "The hospitals place a portion of their contracted reimbursement at risk on performance in the program, and there is enough money at risk for the organization that it gains the C-suite's attention. It quickly galvanizes the organization around aligned goals and helps drive clinical improvements."
Donovan points to several key metrics in 2011 for both hospital and physician PFP programs:
Well-child visits in the first 15 months of life exceeded the national average by 15% and well visits for children, ages 3-6, exceeded the national average by 13%.
76% of women in the program who were between ages 42 and 69 got mammography screenings for breast cancer in the past two years—9% higher than the national average.
72% of office-based physicians in Quality BLUE use electronic prescribing compared to only 36% nationally.
An estimated 351 cases of MRSA with a care cost savings of $9.5 million to $12.2 million were eliminated in the past four years.
An estimated 1,535 central line associated bloodstream infections with care costs savings of $11.2 million to $44.8 million were eliminated in the last five years, saving potentially 184-384 lives.
Donovan says the improvements are particularly impressive because Quality BLUE constantly monitors and improves its own standards. "The program is modified each year to increase the rigor. We raise the bar each year and the facilities continue to be challenged and work hard to achieve the outcomes," she says.
Even patients who aren't in the PFP program are enjoying the benefits of the enhanced quality at participating hospitals, Donovan says. "When we operationalize the program, it applies to any patient who crosses the threshold of a facility's door."
"It is Highmark's program that is really creating the infrastructure requirement and changes in the institutions. That change is applicable whether it is a standard Medicare patient or another health insurer. They are receiving the benefit of the changes that the Quality Blue program helps drive within the institution," she says.
Because the program is adjusted annually, providers are required to implement the newest strategies quickly to improve and measure outcomes in a well-defined way. "That way we can look at that consistent measure across all facilities, and then compare ourselves to external benchmarks," Donovan says.
Highmark's next move with Quality Blue will be to take the lessons learned in the PFP program and apply them to other care delivery models, including a newly launched patient-centered medical home pilot serving Pennsylvania and West Virginia. "We are continuing to look at how do we advance value-based models that will improve the care that is being rendered to our members and ultimately bend the cost trend," she says. "If we can't bend the trend, then it is not going to be sustainable in the long term."
Vermont's yet-to-be-defined leap into state-sponsored universal healthcare could cost as much as $9.5 billion by 2020, about double the $4.7 billion the state now spends on healthcare. That's roughly $14,000 for every person in the state.
But the state plan will still cost less than maintaining the current system of private plans, which could add an additional $550 million to $1.8 billion to the cost of healthcare in the state, according to new estimates released this week.
Whatever plan emerges will at best only slow the 7% annual increases in healthcare costs that are projected until 2020 under the status quo. Vermont, with an aging population and already aggressive coverage for the poor and under-insured, has seen some of the fastest growth in healthcare costs of any state in the nation. In 1992, healthcare represented 10% of the Vermont economy. In 2009, it represented nearly 19% of the state's economy.
"Achieving savings in healthcare spending is a difficult process. In this context, success is measured as reduction in the rate of growth—achieving absolute savings (spending less than in the prior year) is extremely unlikely," according to the report.
Although cost savings are a key component of the plan, the report cautioned that money should not be the only factor when measuring success. "Ultimately, accomplishments will be measured against several standards, including the health of the population, satisfaction of both providers and patients, and the financial sustainability of the system."
Nonetheless, the report said more precise estimates of any projected savings for state-sponsored universal care could be difficult right now because nobody really knows what the plan will look like.
"The actual savings will be determined by decisions yet to be made by the Green Mountain Care Board, the executive branch, and the general assembly, as well as the impact of national initiatives and policy changes, including the amount of federal financial support that we can anticipate," the report's authors wrote.
That savings would be dependent, for example, on cost-containment measures that include payment reform, delivery system changes, and reductions in provider costs—particularly simplifying administrative and paperwork costs that are now associated with private health plans.
If the healthcare system takes action on those and other cost-cutting measures, savings will begin in 2014 and "rise rapidly for the next several years," according to the report.
That savings will also require "substantial investments" in the program's infrastructure, which could cost between $50 million and $150 million.
The American Hospital Association and two hospital group purchasing organizations say they support President Barack Obama's executive order this week to reduce the nation's prescription drug shortage.
Steven Lucio, director for clinical pharmacy solutions at Novation, told HealthLeaders Media that the federal government really can't go much beyond the president's order. "This is a free market and that is what we have to understand. The government can't force drug companies to make products. Unless we want to change that -- and there is a lot of sensitivity these days about what it is practical for the government to do -- I don't think it can be done and I don't think it is appropriate."
Lucio says that the Food and Drug Administration now has only about four people in its drug shortage division monitoring anything from 178 to 211 drug shortages."Four people can't manage that," he said.
While there have been calls to ease restrictions on importing prescription drugs that are in short supply, Lucio says that probably wouldn't work all that well. "The problem is you can't find it," he said.
"If there is a product to be found they will go and try to get it. It's just [that] we can't take all the medication from Europe. However, if the FDA has greater notifications maybe they can do something with a foreign government that would have more time to respond. "
The executive order calls on the FDA to:
Press drug manufacturers to report as far in advance as possible on the potential shortages or discontinued product;
Expedite regulatory review of drugs; and
Review "certain behaviors" by market participants that could include hoarding drugs and reselling them at exorbitant prices
"The shortage of prescription drugs drives up costs, leaves consumers vulnerable to price gouging and threatens our health and safety," Obama said Monday in prepared remarks. "This is a problem we can't wait to fix. That's why today, I am directing my administration to take steps to protect consumers from drug shortages, and I'm committed to working with Congress and industry to keep tackling this problem going forward."
Blair Childs, senior vice president of Public Affairs at Premier healthcare group purchasing organization says that providers shouldn't wait on the government to supply all the answers to the drug shortage problem.
"There are things the government can do that are positive, but there are things we need to do in the private sector," he said. "We need to work with manufacturers and distributors to manage or mitigate the disruptions that occur in the market. How do we help ensure that the products are shared broadly and allocated effectively, that there is a heads up so that folks are preparing when there is an impending shortage. Those are the things we talk to distributors about."
Childs believes that much of the president executive order will do little if anything to solve the short-term shortage of prescription drugs. "But it will help reduced the problems in the longer term. The ultimate long term solution is they need to speed approval at FDA and also for both the new generic products and the active pharmaceutical ingredients," he said.
AHA Executive Vice President Rick Pollack said in a prepared statement that the order "comes at a critical time and is welcome news for hospitals and the patients they care for. The number of drug shortages has tripled in the last six years and the shortages are affecting patient care."
An AHA survey this year found that nearly 100% of hospitals reported a shortage in the past six months, but that most of them rarely -- if ever -- received advance notification of these drug shortages.
"Clinicians need more notice from drug manufacturers so they have time to act to ensure that patient care is not disrupted," Pollack said. "Hospitals are doing their best to reduce the impact of shortages by increasing inventories, buying alternative drugs and training clinical staff on how to deal with drug shortages."
While AHA supports the president's order, Pollack says Congress must step up to pass bipartisan legislation that requires drug companies to tell the FDA as soon as possible of interruptions in supply or discontinuations.
"In addition, we believe that obstacles must be removed so that FDA is able to streamline approval of drugs in shortage," Pollack said.
