"In the face of such a huge and overwhelming tragedy I saw people who really acted in a decent manner."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is John Brebbia's story.
For trauma surgeon John Brebbia, MD, volunteer work in Haiti after the Jan. 12 earthquake was inspired by the memory of a fallen colleague, as much as it was by the knowledge that the practical expertise and care he could provide was desperately needed in the stricken island nation.
"I had a good friend who really would do this kind of thing on a fairly regular basis. That included him joining the military to be a doctor in Iraq," Brebbia says of U.S. Army Maj. John P. Pryor, MD. "Unfortunately, John was killed by a mortar on Christmas Day 2008. I know that if he had still been alive he would have gone to Haiti. Since he was not alive, that space was not filled. I know he would have been on me to go, go, go, and as a tribute to him I went."
Brebbia, of Dover, DE, became one of the thousands of healthcare professionals who travelled to Haiti in the days immediately after the quake.
The United Nations estimates that between 250,000 and 300,000 people were killed by the 7.0 magnitude temblor, although no firm number has been established. Hundreds of thousands more suffered from traumatic injuries as well as illnesses resulting from the ensuing breakdown in public sanitation.
Brebbia was part of a 22-member team of healthcare professionals affiliated with Christiana Care and Bay Health Medical Center in Delaware that travelled to the flattened hillside city of Jacmel, 90 miles south of Port au Prince, eight days after the quake.
"It is an unbelievable, overwhelming sight. You can see the pictures but you cannot even fathom it until you are standing there looking at it," Brebbia says. "Jacmel is built on a hillside. You stand at the foot of the hill and everything is in rubble and there are people living in the streets. More than one person, when they stood there and looked at it, cried because of what they saw."
Soon enough, however, the needs on the ground overtook the shock as the team scurried to provide care in the ruins. "There was one building we thought we were going to use the first day we got there. When we came back the next day to set it up, it had come down in one of the aftershocks," Brebbia says.
With all of the hospitals either flattened or wobbling and unsafe, Brebbia and his colleagues got tents, diesel fuel, and other critical supplies from members of the Canadian army—who also commandeered a generator from the office of a reluctant hospital administrator—and began work. "I would say we worked between 16 and 20 hours a day depending upon the day," Brebbia says, adding that he performed about 30 operations requiring anesthesia during his eight-day mission, and treated hundreds of other patients for wounds and ailments.
As expected, the surgeries for Brebbia often involved amputations of limbs crushed in the falling debris. "Probably the worst one I saw was a 3-year-old whose leg I had to take off. Her leg was totally crushed just above the ankle. I took it off just below the knee," he said. For many of the amputations, Brebbia used an old-fashioned gigli saw because the rescue team wasn't sure if they'd have access to electrical power. With the generator, Brebbia's team powered an autoclave plucked from the rubble of a hospital. "Initially we thought we were gong to have to use and throw away, but the Canadian Army really helped us," he says.
Even with the tremendous sense of mission for the work at hand, Brebbia says the trip was fraught with "huge frustrations."
"Things could have been done better. When we first arrived in Jacmel the mayor said none of us could work because he couldn't verify who we were. They didn't have a plan to verify who we were and they weren't going to let us work," Brebbia says.
Fortunately, a member of the Delaware rescue team was a Jacmel native who had been instrumental in planning the mission. "She got on the mayor pretty good to the point where he just said, 'I will take her word that you are all OK,'" Brebbia says. "Then we went to the hospital and the administrator didn't want us working in his hospital, which was a pile of rubble. There were tents outside. Well, not even tents. They were tarps over trees and patients under the tarps in the open air. The nurses were family members. If you didn't have a family member, you didn't have a nurse."
Fortunately, the Canadian army did a remarkable job maintaining order. "We would call them and say we need diesel fuel and 10 minutes later there is a 40 gallon drum of diesel fuel," he says.
The Canadians also handed out food, tents, and clothing on a massive scale to all parts of the city. "It prevented the people there from becoming unhappy, disgruntled, and dangerous," Brebbia says. "In Port au Prince we saw people killing each other for food. In Southern Haiti that didn't happen because of the way and the speed that the Canadians dispersed the aid was so great that people where having their basic needs met. We never felt threatened. We never felt unsafe."
Now back in Delaware, Brebbia thinks often of Haiti and the huge obstacles the nation still faces as it struggles to recover.
The time he spent there has changed him. "It's impossible not to," he says. And despite witnessing some decidedly dire images, he saw much good that stay with him. "Personally speaking, I saw hundreds of people whose lives were devastated—parents who lost little kids and who despite that were able to treat their neighbor better, or they took in kids who didn't have parents."
"In the face of such a huge and overwhelming tragedy I saw people who really acted in a decent manner. It does make you at least want to try to treat your neighbors better," he says. "Because if these people can do it in the face of that, why can't we do it every day?"
Private, not-for-profit WakeMed Health & Hospitals has asked to look at the public records of rival UNC Health Care and Rex Healthcare to determine if public money was used by either of the state-owned entities to duplicate and shift services to gain an unfair competitive edge.
"WakeMed made the request due to numerous recent transactions by UNC Health Care which have raised serious public-policy questions," said Bill Atkinson, MD, president/CEO of Raleigh-based WakeMed, after the health system's board unanimously voted Monday to make request the records.
"Specifically, the records request is to determine if UNC Health Care and Rex Healthcare are improperly using taxpayer dollars to compete with WakeMed and other healthcare institutions by investing in physician practices and other facilities," Atkinson said.
WakeMed alleges that UNC Health Care and Rex have taken "predatory actions" in Wake County that include recruiting doctors away from WakeMed.
In remarks related to the records request, Dr. Bill Roper, CEO of UNC Health Care said Monday, "our guiding philosophy has been to partner with the best physicians in a community, and to help ensure that we get patients to the right care at the right time. In particular, this means that if the needed care can be provided locally, it should be provided locally, by our partner physicians. Certainly we want to be available at UNC for Wake County patients, as we are to all of the people of North Carolina, for tertiary or quaternary medical care. But we have no intention of siphoning patients.
"We believe that leaders of our state—including the General Assembly, the governor and the leadership of the university system and UNC Health Care—need to carefully consider whether public money should be used to compete with a strong system like WakeMed, which plays a critical role in providing vital healthcare services to Wake County and the entire state," WakeMed's Atkinson said. "While competition is healthy, these recent actions are not enhancing access or adding new physicians to meet demand, but are instead shifting and duplicating existing services, which is not good for the community."
Atkinson said the moves by UNC and Rex appear to be financed with public money at a time when the state of North Carolina is looking at drastic steps to balance the budget, including teacher layoffs, closing of state parks, eliminating 2,000 positions from the University of North Carolina System, and cutting healthcare.
WakeMed's records request to UNC Health Care asks for "all records constituting or reflecting correspondence or communications, other than correspondence or communications relating to identifiable patients" between UNC Health Care, Rex Healthcare, certain officials at UNC Health Care and subsidiary organizations with members of WakeMed's medical staff.
WakeMed also requested "audited financial statements" and other records related to UNC Health Care, Rex Healthcare, Rex Physicians LLC, and Triangle Physician Network, including 990 IRS forms from the named organizations.
WakeMed said it hopes the records will determine the legal status of Rex Healthcare, which is described as a private institution owned by UNC. WakeMed claims that Rex does not provide its fair share of indigent and charity care.
WakeMed, an 870-bed health system, said it has historically provided more than 80% of all charity care in Wake County, yet receives no state or county funding other than limited payments from Medicare and Medicaid.
More than a third of the prescription drugs paid for by Medicaid in 2008 were not on a list of approved drugs in National Drug Code Directory and may have accounted for $6.2 billion of the $24 billion that Medicaid spent on prescription drugs that year, according to an audit by the Department of Health and Human Services' Office of Inspector General.
In all, Medicaid paid for prescription drugs associated with 27,143 NDC listings, for which only 62%— 16,945—had an approved application number listed with the NDC Directory, the OIG has found.
The Food and Drug Administration maintains the NDC Directory, which contains the name, a numeric drug identifier, and the approved application number for each listed drug. Drugs must be FDA approved to qualify for Medicaid payments. In 2008, Congress raised concerns that Medicaid pays for drugs that do not meet this criterion and lawmakers asked OIG examine the FDA approval status of drugs paid for by Medicaid. Previous OIG reports found problems with the accuracy and completeness of FDA's NDC Directory, OIG reports.
Federal auditors examined 2008 Medicaid utilization data for prescription drugs, approval and listing data from FDA, and a targeted manual review to determine the FDA approval status of drugs paid for by Medicaid. The OIG audit found that there was no approved application number in FDA's NDC Directory for thousands of drugs paid for by Medicaid.
"Twelve percent of NDCs under review were listed in the NDC Directory but did not have an approved application number, and an additional 26% were not listed in the NDC Directory at all. As a result, Medicaid could potentially pay for drugs that are not approved by FDA. Without accurate approval and listing information, it is impossible to determine whether these drugs were paid for appropriately," OIG reported.
OIG recommended that the FDA conduct frequent reviews of the NDC Directory to ensure its accuracy and thoroughness, and work with the Centers for Medicare & Medicaid Services and Congress to create legislative or regulatory changes that force drug makers to list all approved products with FDA before they're eligible for Medicaid payments.
In its formal response to the audit, FDA said it generally agreed with the OIG's recommendations, and had already begun implementing several initiatives to evaluate and enhance the quality of drug listing data.
There are few things in our professional lives that provide a greater risk of peril with so few rewards than the annual office holiday party. To many workers, these contrived and tortuously staged attempts at mandatory good cheer are as welcomed as a holiday fruit cake.
Bah! I say get rid of them.
The justifications for the holiday party usually include a sincere expression of appreciation for employees' hard work throughout the year, or providing an opportunity for employees who rarely have contact with one another to meet in a "casual" environment. A closer look reveals flawed thinking. If the office holiday party is your way of telling employees you appreciate their hard work or your strategy for employee bonding, you've probably already failed.
Let's be honest, for many companies, the annual office holiday party is just another business function, wearing a party dress and sipping eggnog. Attendance usually is not mandatory, but miss it at your peril! And it's a little arrogant for supervisors to presume that employees want to spend time socializing with them.
I came across this soul-crushing list of office party "Dos & Don'ts" from Quintessential Careers, an HR consulting firm whose other titles include Surviving the Office Holiday Party. QC reminds us: "You can take advantage of the office party to have some fun and advance your career or misbehave and cripple your career."
Quintessential's tips include:
Do remember that although office parties are intended as social events to reward employees and raise morale, they remain strictly business events.
Do act as though your behavior is being observed every minute (because it probably is).
Don't pass up the invitation to an office party; not attending could hurt your reputation. And when you attend, do spend at least 30 minutes at the party for appearances. But don't overstay your welcome by partying until the wee hours.
Do conduct yourself professionally at all times. Don't use the office party as an excuse to blow off steam. It's still a company function, so proper etiquette and decorum matter.
Don't bring the party lampshade, gag gifts for the boss, or any other crazy stuff you might do at a personal holiday party.
Do enjoy yourself at the party. Employers spend the big bucks to reward their employees, so be sure to enjoy the one holiday gifts you may be getting from the company.
That's right drones. "Enjoy" yourself! Not too much, though. Someone is watching, and one wrong move could cost you your career!
Let me be clear: I'm not criticizing Quintessential Careers. Sadly, they are exactly right. Their recommendations make sense, and that is exactly the problem. What they're describing isn't a party. It's a wake. I'd rather stay home and do my taxes.
I last had a good time at an office party back in college, when I attended the annual gala for the buildings and grounds crew, the guys who plow snow, mow lawns, and buffalo heavy furniture for minimum wage. After a few too many, one of guys committed about 25 or so office party "don'ts," which culminated in a threat to "put the knuckles" to his immediate supervisor and an attempt to throw an empty beer keg at a coworker's car. Now that's an office party!
You might not want to take it to that extreme, but if your holiday party comes with a tacit list of do's and don'ts that is longer than the healthcare reform bill, maybe you should look for another way to express your appreciation.
Here's a suggestion: pay employees for the two or so hours that they'd otherwise have spent at the party, divvy up and give them the money you'd budgeted for the party, tell them to spend the time and the money with whomever and on whatever they want, and wish them Happy Holidays.
Advocate Good Samaritan Hospital in Downers Grove, IL, has won the U.S. Commerce Department's prestigious 2010 Malcolm Baldrige National Quality Award, the nation's highest honor for performance excellence through innovation, improvement, and leadership.
And, for the first time, Studer Group, a healthcare consulting firm in Gulf Breeze, FL, was one of three small businesses selected for the 2010 honor, which also was awarded to seven organizations for only the second time in its 23-year history.
The 2010 Baldrige Award recipients are:
Advocate Good Samaritan Hospital, Downers Grove, IL (healthcare)
Studer Group, Gulf Breeze, FL (small business)
Freese and Nichols Inc., Fort Worth, TX (small business)
K&N Management, Austin, TX (small business)
MEDRAD, Warrendale, PA. (manufacturing)
Nestle Purina PetCare Co., St. Louis, MO (manufacturing)
Montgomery County Public Schools, Rockville, MD (education)
"Today we honor the country's most innovative organizations and the people who make them great," said Commerce Secretary Gary Locke. "This year's recipients of the Malcolm Baldrige National Quality Award embody the ingenuity and creativity that characterizes the American spirit and drives America forward. Innovation is at the heart of U.S. job creation, competitiveness and global strength, and the accomplishments of these outstanding leaders are an inspiration to us all."
"This award is unique in that it honors the collective effort of an entire organization that has systematically strived to achieve excellence in all aspects of its work. Today's honorees demonstrate how teamwork and a shared vision can lead not only to organizational success but also to nationwide advancements in innovation and economic competitiveness," Locke said.
The winners were picked from 83 applicants, all of whom were evaluated by an independent board of examiners in seven areas: leadership; strategic planning; customer focus; measurement, analysis and knowledge management; workforce focus; process management; and results. The evaluations for each recipient included about 1,000 hours of review and an on-site visit by examiners to clarify questions and verify information in the applications.
The award is named after Malcolm Baldrige, the 26th Secretary of Commerce, and was established by Congress in 1987 to foster competitiveness and performance of U.S. businesses. Originally, three types of organizations were eligible: manufacturers, service companies and small businesses. Congress expanded the program in 1999 to include education and healthcare, and again in 2007 to include nonprofit organizations. Since 1988, 86 organizations have won Baldrige Awards.
The Baldrige Performance Excellence Program is managed by the Commerce Department's National Institute of Standards and Technology in conjunction with the private sector.
St. Joseph's Heartland Health of St. Joseph, MO won the 2009 Baldrige award, in part because of process improvement implementation techniques that helped it reduce waste, costs, and errors.
MEDRAD, a medical device maker, also won the Baldrige Award for manufacturing in 2003.
Walter Janke, MD, his wife Lalita, owners of Vero Beach, FL-based Medical Resources LLC, will pay $22.6 million to resolve allegations that they filed false diagnostic codes to inflate Medicare reimbursements, the Justice Department has announced.
The Jankes were the owners of America's Health Choice Medical Plans Inc., a Medicare Advantage Organization, for Medicare beneficiaries. The Jankes also owned Medical Resources, AHC's primary care provider. AHC and MR are now defunct.
The agreement resolves a lawsuit brought by DOJ alleging that the Jankes and MR violated the False Claims Act by causing AHC to falsely increase the severity of diagnoses to get higher Medicare payments.
A federal district court judge in Miami also froze approximately $20 million of the Janke's assets believed to have been generated by the unlawful scheme. The assets and money from the dissolution of AHC are being held in receivership by the Florida Department of Financial Services, and will be used to pay the settlement.
"Patients seeking healthcare should be able to rely on the diagnoses they are given," said Tony West, Assistant Attorney General for the Justice Department's Civil Division. "We will aggressively pursue those who falsify medical diagnoses in order to receive taxpayer funds to which they are not entitled."
More than one in 10 family physicians may close their offices if Medicare slashes payments next year, according to an online survey of American Academy of Family Physicians members who have an ownership stake in their medical practices.
The survey asked family physicians in September about the impact of a pending 23% Medicare pay cut that was scheduled to take effect December 1, but which was subsequently delayed until January 1 by Congress. Nearly 13% of survey's 516 responding physicians said they would consider no longer seeing patients if Congress failed to override the mandatory pay cuts that will deepen to 25% in the coming months.
"This survey demonstrates the serious threat to Americans' access to healthcare that is posed by the current formula for paying physicians to care for the elderly and disabled," said Roland Goertz, MD, president of the American Academy of Family Physicians. "You can imagine how many more physicians will be forced to close their doors if a 25% or even bigger pay cut goes into effect next year. If you ran a business and knew that up to 30% of your customers were going to reduce your payment by 25% or more, what would your business do?"
AAFP membership data show that Medicare patients comprise as much as 30% of family physicians' patient population. More than one in four patients in rural family physician practices areas depends on Medicare for coverage.
The 2010 survey found that among family physicians who maintain their practices, 62% said they may be forced to stop accepting new Medicare patients, and 73% said they would have to limit the number of Medicare appointments because of the reimbursement cuts.
Goertz said that the impact of the cuts will likely be felt most by elderly and disabled Americans who depend on Medicare, and for military families enrolled in TRICARE. He said to an Oct. 13 AARP survey that showed 81% of AARP members who receive Medicare and 86% of members not yet eligible for Medicare are concerned about the impact of the Medicare physician pay cut on their access to a doctor.
Family physicians are the primary source of medical care for 60% of people age 65 and older who report having an individual health professional as their usual source of care. Elderly and disabled Americans in rural and underserved areas, where family physicians often are the only healthcare professionals in town, would be particularly hard-hit, Goertz said.
"We have reached a point where all patients—children, their parents and their grandparents—face the real prospect of losing their doctors," said Goertz. "Medicare—the program designed to ensure that our elderly have access to health care—could force the very doctors who care for them out of business. And if that happens, all patients in that community—regardless of their insurance coverage—would lose access to needed healthcare."
Emergency department directors are reporting inadequate on-call trauma coverage, and many report a loss or downgrade of their hospitals' trauma center designations, according to a survey in the journal Academic Emergency Medicine.
"Without adequate on-call surgical coverage, our healthcare system cannot provide for emergency and trauma patients," said Mitesh Rao, MD, lead author of the survey and study: The Shortage of On-Call Surgical Specialist Coverage: A National Survey of Emergency Department Directors.
Rao, with the department of emergency medicine at Yale University, and clinical scholar with the Robert Wood Johnson Foundation, said 21% of ED deaths and permanent injury can be linked to shortages of specialty physician care. "Transferring patients significant distances to an available specialist is sometimes the only option, but it can create a dangerous delay in care," he said.
The survey found that 60% of respondents could no longer provide 24-hour coverage for at least one medical specialty in the last four years. More than three-quarters of respondents reported that their EDs have inadequate coverage for plastic surgery, hand surgery and neurosurgery. Almost one-quarter of survey respondents reported an increase in patients leaving before being seen by a specialist.
"More than 70% of respondents noted difficulties with their neurosurgical coverage, and 80% reported inadequate hand surgery coverage," Rao said. "Patients with traumatic brain or hand injuries have a substantial risk of lifetime disability if they cannot get appropriate care in a timely fashion. We need to change the system to better handle the incentives and disincentives for surgeons who are willing to take call in the emergency department."
Teaching hospitals fare better than non-teaching hospitals, with inadequate coverage reported at 68% of the former and 78% of the latter. However, that may increase the burden on what the Institute of Medicine considers "core safety net providers" if non-teaching hospitals increasingly transfer patients who need surgical care to teaching hospitals, the study said.
"If you are in a car crash or even slice open your hand carving the holiday turkey, you need fast access to emergency surgery," said Sandra Schneider, MD, president of the American College of Emergency Physicians. "This study highlights one of the most critical threats to the emergency medical care system. As we implement healthcare reform, lawmakers must take steps to ensure that emergency surgery is available to anyone who needs it. Medical liability reform would be a great first step."
The nation's hospitals reported 16 "mass layoffs" of 50 or more employees in October, up from 10 in September, as the number of job cuts in 2010 keeps pace with the record 152 mass layoffs in 2009, Bureau of Labor Statistics data show.
In the first 10 months of 2010, there have been 128 mass layoffs at hospitals, averaging more than 10 mass layoffs each month. At this pace, hospitals would record 153 mass layoffs in 2010.
Through October, hospital layoffs resulted in 9,898 initial claims for unemployment benefits, which would project to a record 11,877 claims for all of 2010. In 2009, there were 11,787 initial claims for unemployment linked to hospital layoffs, BLS data show.
In the first three quarters of 2010, there were 50 extended mass layoffs of 31 days or longer involving 9,269 workers, which resulted in 6,453 initial unemployment claims. In all of 2009, there were 71 extended mass layoffs affecting 14,131 employees, with 12,405 initial unemployment claims, BLS data show.
Extended mass layoffs are a subset within mass layoffs for reporting purposes, BLS says.
Despite the layoffs, overall hospital employment growth continues in 2010, albeit at a slower pace than in the years preceding the recession.
Hospitals created 5,100 payroll additions in October, and 31,600 payroll additions so far this year, a rate of job creation that is more than double that for the same period in 2009, BLS preliminary data show. Hospitals reported 86,200 payroll additions in the first nine months of 2008.
Louisville, KY-based Humana Inc. and Norton Healthcare jointly announced this week that they have launched the region's first commercial Accountable Care Organization.
The Louisville pilot ACO, one of five such sites in the nation, was selected by the Engelberg Center for Health Care Reform at the Brookings Institution, and The Dartmouth Institute for Health Policy and Clinical Practice.
"Norton Healthcare is proud to be a participant in the Brookings-Dartmouth ACO Pilot Project and we feel this is a tremendous opportunity to participate in an alternative model for health reform," said Steve Hester, MD, Norton Healthcare CMO. "Considering our healthcare system's industry-leading commitment to measuring and openly reporting on the quality of our care; our progress toward a system-wide integrated electronic medical record; and our large base of employed primary- and specialty-care physicians, Norton Healthcare was the logical choice in our region to be an ACO pilot participant."
The other pilot sites include Carilion Clinic, Roanoke, VA; Tucson Medical Center, Tucson, AZ; HealthCare Partners Medical Group, Torrance, CA; and Monarch HealthCare, Irvine, CA. Humana has worked with Brookings-Dartmouth since 2008 on exploring the ACO concept and other innovative payment models.
"Norton Healthcare's work in developing an integrated health care delivery system and Humana's commitment to continuous improvement in quality provide a strong foundation from which to pilot the payment reforms central to ACOs," said Elliott Fisher, MD, director of the Center for Population Health at The Dartmouth Institute for Health Policy and Clinical Practice.
The Brookings-Dartmouth team, led by Fisher and McClellan, is working with Humana and Norton Healthcare to offer technical and strategic support in the implementation of the ACO model. Each ACO site defines the patient population it serves and establishes a spending target that reflects the predicted costs for their patients. The goals of ACOs are to improve efficiency and effectiveness of care and slow spending growth. ACO providers who can demonstrate that they meet these goals will receive in return a portion of the savings achieved.
"The ACO model really gets at bending the cost curve, which is so vital to achieving a sustainable system," Fisher said. "Only health systems that can slow their spending growth, compared to previous years, will have the opportunity to receive shared savings."
Norton-Humana ACO already have identified several initial areas of emphasis, including improvements in preventive screenings and tests, such as mammograms, and vaccinations, better management of chronic illnesses, such as heart failure, more effective treatment of common problems, such as back pain, use of generic drugs, and improved access to the appropriate level of care, rather than emergency department treatment.
The Brookings-Dartmouth team will evaluate the pilots to see how ACOs can impact payment reform, with the hope that a model can be replicated across the nation, building on health reform legislation which will likely make ACOs a voluntary option with Medicare participation in 2012.
Norton Healthcare is the region's largest hospital and healthcare system, with 44% market share, and includes five Louisville hospitals; 12 Norton Immediate Care Centers; 10,900 employees; more than 400 employed medical providers; and nearly 2,300 total physicians on its medical staff.
