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.
Humana Inc. has announced that it will pay $790 million to buy Addison, TX-based Concentra Inc., a provider of urgent care, physical therapy, and wellness services with 300 facilities in 42 states.
Louisville, KY-based Humana says nearly 3 million of its customers live near a Concentra center, which also operates more than 240 worksite medical clinics.
"Concentra brings solid experience across a number of fronts that fit well with our consumer-focused strategy and will allow both organizations to provide a wide array of services to individuals needing access to convenient and affordable high-quality healthcare," says Michael B. McCallister, Humana's chairman/CEO. "We are excited about the opportunity to acquire a strong stand-alone business that reinforces our core businesses while providing both revenue diversification and opportunities for strategic expansion longer term."
Concentra CEO James. M. Greenwood says the acquisition will provide an opportunity to expand services to patients and employers. "Concentra's focus on evidence-based, cost-effective medical care and a service-driven culture parallels that of Humana and ultimately results in tremendous opportunity across the combined enterprise," Greenwood says.
Concentra generates annual revenues of about $800 million. The transaction is subject to regulatory reviews but is expected to close in December.
Requiring physicians to ask for preauthorization from health insurance companies harms patient care, and creates an expensive and confusing claims process, according to a national survey released by the American Medical Association.
"Intrusive managed care oversight programs that substitute corporate policy for physicians' clinical judgment can delay patient access to medically necessary care," said AMA Immediate Past President J. James Rohack, MD. "According to the AMA survey, 78% of physicians believe insurers use preauthorization requirements for an unreasonable list of tests, procedures and drugs."
The AMA said the national survey—released this week— of approximately 2,400 physicians is an attempt to quantify the burden of preauthorization mandates for a growing list of routine tests, procedures and drugs. Physicians complained that preauthorization delays or interrupts patient care, wastes time, and complicates medical decisions.
The survey found that:
37% of physicians experience a 20% rejection rate from insurers on first-time preauthorization requests for tests and procedures, and 57% experience a 20% rejection rate on first-time preauthorization requests for drugs.
46% of physicians had difficulty getting approval from insurers on 25% or more of preauthorization requests for tests and procedures, and 58% experience difficulty getting approval from insurers on 25% or more of preauthorization requests for drugs.
63% of physicians typically wait several days to receive preauthorization from an insurer for tests and procedures, while 13% wait more than a week. And 69% of physicians typically wait several days to receive preauthorization from an insurer for drugs, while 10% wait more than one week.
64% of physicians have trouble determining which test and procedures require preauthorization, and 67% have trouble determining which drugs require preauthorization.
A Health Affairs study published in 2009 showed that navigating the managed care maze costs physicians $23.2 to $31 billion a year.
AMA said its survey showed that preauthorization policies create costly bureaucratic hassles that take time away from patients. Physicians in the survey said they average 20 hours each week dealing with preauthorizations.
"Nearly all physicians surveyed said that streamlining the preauthorization process is important and 75% believe an automated process would increase efficiency," Rohack said. "The AMA is urging health insurers to automate and streamline the current cumbersome preauthorization process so physicians can manage patient care more efficiently."
The federal government on Monday unveiled a $290 million loan repayment program that could reimburse primary care physicians and dentists up to $60,000 if they agree to practice for two years in medically underserved areas.
Health and Human Services Secretary Kathleen Sebelius announced the launch of the application cycle for the National Health Service Corps Loan Repayment Program, during a visit to Total Health Care, a community health center in Baltimore.
"As we continue to seek ways to impact both the primary care workforce shortage and the increasing debt burden on new providers, NHSC serves as a model for addressing both challenges simultaneously," Sebelius said. "Increasing access to primary care physicians who can support the physical and mental well-being of individuals can help prevent disease and illness, and ensure everyone—regardless of where they live—has access to comprehensive, high quality care."
The Affordable Care Act provides more flexibility in how the Corps administers the loan repayments. In addition to raising monetary awards, the Corps will give members the option of working half-time to fulfill their service obligation and provide credit for some teaching hours, HHS said.
"By the end of FY2011, we expect that over 10,800 clinicians will be caring for more than 11 million people, more than tripling the National Health Service Corps since 2008," says NHSC Director Rebecca Spitzgo. "By 2015, with the historic funding opportunities offered by ARRA and the Affordable Care Act, the Corps will support more than 15,000 new primary care professionals."
Providers can apply to the NHSC loan repayment program online.
New medical loss ratio regulations issued Monday will require health insurers in 2011 to spend between 80% - 85% of consumers' premiums on direct care for patients and care quality improvements, the Department of Health and Human Services has announced.
The new rules will affect about 74.8 million insured Americans. In 2012, up to 9 million Americans could be eligible for rebates totaling up to $1.4 billion -- or $164 per person in the individual coverage market if insurers don't meet the medical loss ratio, HHS said.
HHS Secretary Kathleen Sebelius said the medical loss ratio provision of the Affordable Care Act will make the insurance market more transparent and easier for consumers to purchase plans at a better value. "These new rules are an important step to hold insurance companies accountable and increase value for consumers," she said.
The medical loss ratio regulation outlines disclosure and reporting requirements, how insurance companies will calculate their medical loss ratio and provide rebates, and how adjustments could be made to the medical loss ratio standard to guard against market destabilization.
"These rules were carefully developed through a transparent and fair process with significant input from the public, the states, and other key stakeholders," said Jay Angoff, director of the Office of Consumer Information and Insurance Oversight at HHS. "As we build a bridge to 2014 when better, more affordable options are available to consumers these rules will help make health insurance fairer for consumers now."
The Affordable Care Act required the National Association of Insurance Commissioners to develop uniform definitions and methodologies for calculating insurance companies' medical loss ratios. The regulation issued today certifies and adopts the NAIC recommendations submitted to the Secretary of HHS on Oct. 27.
In a statement released Monday, America's Health Insurance Plans (AHIP) President and CEO Karen Ignagni said, "These regulations acknowledge the potential for individual insurance market disruption and take a first step toward minimizing such disruptions. The potential for disruption to employer-provided coverage should also be acknowledged and addressed. In addition, more consideration needs to be given to the cost of federally mandated investments in modernizing claims coding and the value of health plans' programs to prevent fraud."
Cecil B. Wilson, MD, President of the American Medical Association said in a statement, "We are pleased that HHS did not allow the health insurance industry to claim administrative expenses as medical losses, artificially inflate the medical loss ratio, or calculate their ratios at the national level."
Healthcare reform will dramatically change how physicians conduct business and likely will mean the end of full-time, independent, private practitioners accepting third-party payments, according to a new report.
Instead, the survey and report commissioned by Boston-based The Physicians Foundation predicts that physicians will become employees, part-time workers, administrators, operate cash-only "concierge" practices, or leave medicine altogether.
"The private practice physician is rapidly disappearing," said Lou Goodman, president of nonprofit The Physician Foundation. "Both market forces and the healthcare reform law are forcing physicians to find new ways of running a practice. We are extremely concerned about how this will affect patient care."
The report, Health Reform and the Decline of Physician Private Practice, conducted and compiled by physician recruiters Merritt Hawkins, includes results from a national survey of 2,400 physicians, only 26% of whom said they would continue practicing the way they are in the next one to three years. The remaining 74% said they would retire, work part-time, close their practices to new patients, become employed and/or seek non-clinical jobs.
The survey also found that a majority of physicians did not support health reforms, which they believe will increase patient volume while decreasing revenues.
Based on the discontent made plain in the survey and other data, the report's advisory panel, which included seven physicians, also predicts that:
The federally mandated reforms will have a transformational effect on healthcare delivery, with substantive and lasting change, unlike the "false dawn" of the healthcare reform movement in the 1990s.
Independent, private physician practices will be largely, though not uniformly, replaced.
Most physicians will be forced to consolidate with other practices, become hospital employees, or align with hospitals and health systems for capital, administrative, and technical resources.
Emerging practice models will vary by region, with a proliferation in larger accountable care organizations, private practice medical homes, large independent groups, large aligned groups, community health centers, concierge practices, and small aligned groups.
Reforms will drastically increases compliance obligations and potential liability under federal fraud and abuse statutes. More funding for enforcement, more whistleblowers, and the suspension of the government's need to prove "intent" will exacerbate compliance issues for physicians.
Reforms will worsen physician shortages, and will not address primary care shortages or physician distribution issues.
The demand to care for more patients, with higher quality, less cost, increased reporting and tracking demands, with enhanced liability and reimbursement issues, will put more stress on physicians, particularly those in private practice.
Congress' refusal to provide a permanent fix to the Sustainable Growth Rate formula will be a disincentive for physicians, who will likely limit patient access.
Despite its many problems, healthcare reform was necessary and inevitable and many of the changes mandated by the "formal" reforms likely would have occurred on their own with the "informal" delivery of care, owing to economic and demographic forces.
The Rural Nebraska Healthcare Network, a consortium of nine hospitals and clinics in western Nebraska, has broken ground on a new $18 million fiber optic medical network that—when completed—will extend across the Nebraska panhandle.
The ceremonial groundbreaking last Friday at Regional West Medical Center in Scottsbluff, NE, marks the start of a project made possible by federal funding under the Rural Healthcare Pilot Program of the Federal Communications Commission.
RNHN will connect nine primary care hospitals and dozens of affiliated clinics creating one of the most advanced and robust medical technology networks in Nebraska.
“This fiber network will facilitate the deployment of advanced medical technologies, and vastly improve patient care and physician communication,” said Lisa Bewley, CIO for Regional West Medical Center.
RNHN contracted with Zayo Group, a Colorado-based provider of bandwidth infrastructure and network neutral colocation services, to build the network that will piggyback commercial telecommunications products to be offered in underserved rural Nebraska.
The proposed 750 mile fiber network spans 12 counties in western Nebraska, and will connect to national research networks such as National Lambda Rail and Internet 2 in Denver, CO. Adesta, LLC, a Nebraska company is about to begin the network construction, which has been two years in the planning.
The average, per capita cost of providing healthcare services in the United States rose by 7.08% for the past 12 months ending in September, a rate of growth that has slowed slightly, but which is still well above the 1.1% overall inflation for the same period, according to the latest monthly study by Standard & Poor's.
The new numbers are consistent with a trend that from September 2000 to September 2010 has seen healthcare inflation rise 48% while overall Consumer Price Index has risen 26% for the same period, U.S. Bureau of Labor Statistics data show.
A further breakdown of the data from the S&P Healthcare Economic CompositeIndex show that physician and hospital claims costs associated with commercial plans rose 8.54% for the 12-months ending in September, while similar claims associated with Medicare rose 4.68%, despite Medicare's sicker, older population.
The annual growth rates calculate a percent change of the 12-month moving averages of the monthly index levels when compared with the same month in the previous year.
The trends mark a slight deceleration of growth from the 7.31% reported for the 12 months ending in August, 2010. Physician and hospital claims costs associated with commercial plans and with Medicare rose 8.64% and 5.07%, respectively, in the 12 months ending in August.
"While annual expenditures for Medicare and commercial insurance programs continue to rise faster than either inflation or GDP growth, the pace has slowed slightly in the last seven months" said David M. Blitzer, chairman of the Index Committee at S&P. "In the 12 months ended in September, the composite index rose 7.08% compared to the 12 months ended last February when the increase was 8.39%. Expenditures associated with commercial health insurance plans continue to outpace expenditures for Medicare; the commercial increase over the 12 months to September was 8.54% vs. 4.68% for Medicare."
Blitzer said September's results are consistent with a "moderating trend" in expenditure increases that have been seen in most of the indices in the S&P composite. He said a comparison of the 12 months to September with the 12 months to last February revealed that Medicare and the Hospital Medicare indices showed the most moderation in costs while the Hospital Commercial Index saw a slight increase in the growth of expenditures. "While encouraging, these trends can shift quickly as shown by patterns over recent years. Further, none of these data reflect the healthcare legislation enacted earlier this year," Blitzer said.
A further breakdown of the year-over-year change in the S&P Healthcare Economic Indices for the 12-month period ending September 2010 show that—despite the "moderating trend"—cost increases in healthcare are well above the Consumer Price Index, including: Hospital Index 7.15%; Hospital Medicare Index 3.96%; Hospital Commercial Index 9.62%; Professional Services Index 6.82%; Professional Services Medicare Index 5.42%; and Professional Services Commercial Index 7.42%
