Alan Morgan, CEO of the National Rural Health Association, is blasting a federal report that recommends stripping critical access designation from any hospital that was brought into the program under a state "necessary provider" designation. "The practical effect is that it would kill rural health," Morgan says.
Hundreds of small hospitals across the nation could lose their critical access status and the extra funding that goes with it if the federal government acts on a series of recommendations made public this week.
The Department of Health and Human Services' Office of the Inspector General has recommended that Congress allow the Centers for Medicare & Medicaid Services to strip critical access designation from any hospital that was brought into the program under a state "necessary provider" designation.
Brian Jordan, a program analyst for OIG's Office of Evaluation and Inspections in Chicago, said in a podcast produced by his office that nearly 1,000 of the approximately 1,300 critical-access hospitals in 45 states gained the "permanent exemption" under the necessary provider designation. Congress closed the loophole in 2006, but grandfathered in the hospitals.
Without that designation, Jordan said about 800 hospitals would not have met location requirements in 2011 because they were too close to another hospital.
"We were concerned that some of these hospitals may not be providing critical access to rural patients because they were located very close to other hospitals that could provide similar services," Jordan said. More than 300 critical access hospitals were less than 15 miles from another hospital in a 2011 review.
Jordan said that Medicare could save $1.3 million for every critical access hospital that is stripped of its designation, and that "de-designating" critical access hospitals that are less than 15 miles from the nearest hospital would save Medicare $449 million a year.
"Remember, necessary provider hospitals never had to meet the distance requirement," he said. "And, until March of 2013, CMS never went back to check that other critical access hospitals still met the location requirements. With new hospitals being built and towns expanding, some of these hospitals might no longer qualify for critical access hospital status. Since we pay these hospitals more to provide this critical access to rural patients, we wanted to know if these increased payments are tax dollars well spent."
Alan Morgan, CEO of the National Rural Health Association, blasted the report.
"The practical effect is that it would kill rural health," Morgan says. "I know that is a strong statement, but OIG viewed this with blinders on, not looking at how healthcare is delivered in rural America. We aren't talking about just closing 800 rural hospitals potentially. We are also talking about closing the EMS services in many of those communities and removing access to mental healthcare in many communities. Most of these hospitals have provider-based rural health clinics and a lot of these hospitals have nursing home beds in effect."
"OIG is viewing this strictly [as] a narrow payment issue and not recognizing what this will do to the rural healthcare safety net," he says. "It's about access and this report is only about finances and not access. It is a spending and finance issue and we seem to have forgotten the rationale for the creation of this program, which was an access issue."
Jordan said OIG is merely recommending that "CMS periodically check if each critical access hospital still provides services that rural beneficiaries can't easily get somewhere else, and therefore deserves the increased financial support from Medicare and beneficiaries. We also recommend that necessary providers be required to meet the distance requirement."
If CMS follows the OIG recommendations, Jordan believes it would not necessarily result in nearly two-thirds of critical access hospitals losing their designation.
"These hospitals are costly for Medicare and beneficiaries, but we have to balance cost concerns with hospital access for rural beneficiaries," Jordan said on the podcast. "With that balance in mind, we recommend that CMS create alternative location related requirements for critical access hospitals that don't meet the distance or rural requirements. For example, CMS could allow critical access hospitals to keep their designations—if they serve communities with high poverty rates."
Morgan says the nation's hospitals are already reeling from the effects of the 2% sequestration cuts and that removing the critical access designation, which theoretically allows hospitals to collect 101% of Medicare costs, "effectively closes them."
"The first thing we are going to hear argued back at us is that OIG isn't recommending that they shut the doors, but they are," Morgan says. "When they're talking about removing that designation from facilities where a large percentage of them are operating in the red already, that will effectively close them. So it's not an honest argument saying that 'we are not recommending closing 800 rural hospitals.'"
According to our May Intelligence Report, while 84% of healthcare leaders expect their ED patient volume to increase within the next three years, at least six in 10 expect their ED's operating margins and reimbursement rates to decline during that period.
What is your organization doing to improve ED performance and ensure the ED's operational viability?
Tim Maurice CFO
UC Davis Health System
Sacramento, Calif.
On the ED and community need: Our emergency department is very important to the community. We are the only level 1 trauma center for inland Northern California, representing an area from the Oregon border to Bakersfield, Calif.
On getting Lean and changing processes: We have been engaging quite extensively in Lean Six Sigma process improvement in the emergency services area to improve the patient experience and throughput throughout the facility. We have put a physician in the triage area so they can perform the screening exam and test the patients while they are waiting to be seen. We implemented a nurse navigator process to have the nurses work with the physician teams to navigate patients through the emergency services area.
On building new protocols: We have been involved in a number of research projects regarding appropriate use of emergency services for patients with head traumas, patients that may have bacterial infection or a meningitis risk. We are really on the cutting edge in identifying protocols that can be used effectively to determine the right level of care for patients to reduce the risk of excess radiation exposure.
On the changing role of the ED: With the Affordable Care Act, I don't expect to see a big increase in the emergency usage. I do expect that over time we are going to use varying levels of care in the emergency department. We feel emergency services are a viable resource not just for the real severe emergencies but also for other levels of care that can be provided within the triage capability of the team.
Kyle Martin, MD Medical Director for the Emergency Department
St. Mary’s Hospital
Madison, Wis.
We anticipate that our volumes will continue to climb as compensation decreases. We are going to do a deeper dive on managing our costs. One of the pieces we have looked at recently is how we compare to some of our hospital peers. For example, indirect care time for staff is actually quite a bit higher than it is most of our peer hospitals.
Our department has been markedly successful in working our door-to-doc time. When I started as medical director in 2007 our average door-to-doc time was around 45–50 minutes. We have gotten that down to be around 13 or 14 minutes. That really is the core to having a safe ED where patients are getting in front of a provider in a relatively short period of time to make sure they don't need a stabilizing intervention, but also improving how quickly they can move through the ED.
We are looking at how we are staffed and other ways where we could continue to maintain that level of efficiency and that level of care while perhaps relying less on the nursing hours and seeing if there are more tasks that technicians or paramedics could help with. As we shift toward value and away from volume it is important that you are doing things in as efficient a manner as possible.
David M. Zechman,FACHE
President and CEO
Ozarks Medical Center
West Plains, Mo.
We started with improving the physician and nursing documentation chart along with audit reviews, not only by our documentation integrity team, but also by our medical director, Dr. Kathryn Egly. As part of that, hours of one-on-one education have been provided to the ED physician staff and nurses on appropriate documentation to show the true level of care that a patient is receiving.
The second thing we have done is decrease a metric we call the left before exam rate. Five or six years ago our LBE before our new ED opened was anywhere from 5%–7%. In 2012 it was 3.2% and year to date it is 1.2%. We are capturing more patients who were leaving the ED without being seen and we've done that through putting a nurse practitioner in a fast track right at triage.
Finally we have terrific physician leadership in our emergency department. I am a big believer in physician champions with clinical service lines. Under Dr. Egly's leadership has we are creating new mechanisms for efficiency as well as measuring quality and holding the physicians accountable for quality and patient satisfaction.
Alex M. Rosenau, DO, FACEP, CPE
Senior Vice Chair of Emergency Medicine
Lehigh Valley Health Network
Allentown, Pa.
President-elect, American College of Emergency Physicians
Coordination of care is very important. We are looking at observation unit benefits. If a person is admitted for emergency medicine observation, our patients are in and out in an average of 18 hours. But we have some very well defined protocols for observation units; for instance, when internal medicine creates an observation status for an admitted elder patient that has multiple medical problems, we aren't going to be able to get them in and out in 24 hours because there is so much to deal with.
Many hospitals have established a rapid assessment unit where we placed physicians in triage and we emptied out the waiting room. So instead of having a triage nurse, the patient comes right into an area where a doctor, a nurse and the registrar come into the room together, listen to your history, and get your treatment going. We see much more of a role for nurse practitioners and advance practice clinicians.
We need a better infrastructure to interact with and we need to continue making those ties integrated with the outpatient world. At Lehigh Valley Hospital–Cedar Crest, we established a pediatric hospital within the hospital and we opened a pediatric emergency department with 12 beds. It has a lot of support from the community. We have the people who are committed to the care of children and that has also opened up space in the main ED which can then be filled with that coming tsunami of adult patients.
"There is nothing special about me. I am just a doctor trying to do what I know how to do," says Thomas E. Albani Jr., MD, who helped establish and helps run a free health clinic in Ohio. The American Academy of Family Physicians has named him 2013 Family Physician of the Year.
Between his solo practice, his volunteer clinic work and other community and professional service, Canfield, OH-based family physician Thomas E. Albani Jr., MD, figures he puts in "anywhere between 60 to 70 hours or more than that" each week.
Thomas E. Albani Jr., MD
(Photo: Ohio State University College of Medicine)
"You get tired, but honestly I feel pretty good," says Albani, 56. "There is that old axiom that if you do what you love you never work a day in your life. That is where I am at. I love what I am doing. If I am having a bad day the thing that makes me the most happy is when I go in to see my patients. They pick me up. I enjoy interacting with folks. It always helps."
Albani's longstanding dedication and commitment to providing healthcare access for the less-affluent in his native Youngstown, OH region have earned him the 2013 Family Physician of the Year award from the American Academy of Family Physicians.
In addition to his nearly 30 years of private practice, Albani helped establish the Midlothian Free Health Clinic, which works out of a church and serves a working poor patient base. The clinic gets no public money and is staffed by volunteers who provide patients with a primary care medical home. Albani, who is the medical director at the clinic, and his staff also help patients navigate the healthcare maze when more advanced, sub-specialty care is needed.
Albani says he feels "extremely happy" to have the opportunity to help people whose health concerns might otherwise not be addressed. "Most of these people are working jobs like McDonalds—low income jobs. They didn't make enough to pay for health insurance and they made too much money to qualify for public assistance. They continue to work because they feel they should. That is the mindset of a large number of folks here," he says.
A community effort
Albani and other providers work arm-in-arm with volunteers from Bethlehem Lutheran Church in Youngstown, which provides the space for the clinic and provides other support. "The church does the nuts and bolts of trying to raise money in the community to take care of patients and I took care of the medical side of it, which was organizing the layout of the church and where we see people and organize the patient flow and what kind of stations we needed."
"Somebody doing triage, somebody doing vitals, somebody doing check in and check out. That was my contribution," Albani says. "By no means am I the big chief in there. It is very much a community effort and a large number of people are there every time to help when we do the clinic."
"We have several thousand patients we see now tied into the program. On any given night we see between 40-50 people," he says. "The first six months it was just me, because I wanted to get the nuts and bolts worked out. Now we have expanded and typically there are five providers there each night, usually physicians I have recruited, but there are two nurse practitioners who help us as well. And we have medical residents who serve as part of their education."
Albani also sits on the board at Access Health Mahoning Valley, which he helped found in 2008, and which provides primary care to residents of Mahoning and Trumbull counties, aged 19 to 64, who are uninsured and ineligible for public assistance.
Essentially, Access Health is a larger version of the Midlothian clinic model, supported by local businesses, health, and political leaders who want to reduce medical costs to the community by helping patients avoid expensive and unnecessary emergency room visits.
"I got involved with Access Health because I had things I could contribute to help guide them, or at least add my two cents worth to help give them some reasonable input on the concrete things we have done that have made a difference at Midlothian," he says.
Malpractice not a concern
"Access Health is on a bigger scale. Instead of one small area with one church that is seeing whatever patients they can see Access Health is trying to replicate that same picture in other parts of Mahoning and Trumbull counties and expand as time goes by to bigger area as well."
Albani enthusiastically recruits healthcare professionals to serve in the clinics, although he meets some resistance from physicians because of malpractice concerns.
"I would say first of all, if you live your life in fear by worrying about things like malpractice you will never accomplish anything," he says. "If that is the case don't see any patient because every single patient can sue you. We are covered by the Good Samaritan laws in Ohio that prevent people from suing you if you are not getting reimbursed. And really if someone wants to sue me because I am trying to help them and I am not charging them for it, go for it. I don't see that as an obstacle, but a lot of people do."
For physicians and other community activists who want to start a clinic, Albani says they shouldn't fixate first on raising money before they actually provide services.
"That is what we did. We started seeing patients. I said I am not worried about the donations. They will come once they see what we are doing and that is exactly what happened," he says. "Nobody wants to contribute any money for an idea. You have to have something to show people that they can see that is tangible and that helps people in the community understand what you are about and what you are trying to do."
"Until that happens," he says, "you are probably not going to be very successful with building a donor base. Besides, you don't need much to start with. In primary care you don't need much in the way of instrumentation. With a very small amount of equipment you can accomplish quite a bit."
"I went into medicine to help people"
While the efforts of Albani and other community activists in Youngstown are unquestionably noble, is it realistic or fair to have a healthcare delivery system that relies upon a small group of volunteers sacrificing a sizeable chunk of their lives in the service of others?
"There is a subset of people who have fundamental problems with the concept of the free clinic to begin with," Albani says. "The feeling is that everyone should have to pay for what they get. I don't believe in doing charity work and that our government needs to set up a system that will cover these people instead of us having to do it for free. The government is living off of our backs."
"Yes, I understand all that but I went into medicine to help people and that is all I can tell you. So, I feel like each of us in our own way do what we can to help the community. That is the basis of everything I do in medicine," he says.
"My whole family has been involved at various times helping with the clinic. They come as they are able to. That is what happens with other physicians. Those who are interested, we rotate them through so they are not there all the time. I am there each week but most people come periodically and that seems to work so that they are not overwhelmed. So it is very doable."
Responsibility goes with the award
While he was first "very uncomfortable" about earning the Family Physician of the Year Award, Albani says the award has practical purposes.
"You don't go into medicine looking for accolades. I'm not out there for awards. There is nothing special about me. I am just a doctor trying to do what I know how to do," he says.
"But as a little time has gone by I've come to realize that there is a responsibility and an obligation that goes with the award. The award was given because they feel I represent what we as family physicians do. That is important at a time when you have the government and insurance companies telling us what doctors are all about. It sets a spark. It's a great example."
The American Medical Association, a number of other national provider associations, and 47 state medical societies are urging the Centers for Medicare & Medicaid Services to preserve federal funding for state-based quality improvement organizations.
Some of the nation's largest provider associations are asking the federal government to spare state-based quality improvement organizations from proposed funding cuts or significant reorganizations.
The American Medical Association, the National Rural Health Association, the American Health Care Association, and the American Health Quality Association have sent letters to the Centers for Medicare & Medicaid Services to call for maintaining its long-standing support of QIOs, which since 1984 have collaborated with physicians, hospitals and other providers to coordinate care for Medicare patients at hospitals, physicians' offices, long-term and post-acute care facilities, health clinics, and at home.
CMS in May made a request for public comment on proposals to cut funding to many state-based QIOs and fund a few regional QIOs instead. "The need for QIOs has evolved from utilization review alone to convening complex local communities that can span state boundaries, particularly as health delivery systems become more horizontally and vertically integrated and new alliances form," CMS said in its request-for-comment letter.
"Now that the QIOs' role in healthcare quality improvement has changed, it is time to think about new and better ways to approach QIO work. Beginning in August 2014, we will launch the next round of QIO Program contracts with a new approach to essential program operations and the service areas for QIOs. In doing so, we hope to maximize program efficiency while improving the quality of care Medicare beneficiaries receive."
Mark Parkinson, president/CEO of AHCA, which represents more than 12,000 non-profit and proprietary skilled nursing centers, assisted living communities, sub-acute centers and homes, said that any changes that could potentially disrupt more than three decades of careful and structured collaboration between QIOs and local providers would prove counterproductive.
"For more than a decade, our skilled nursing members from across the country built trusted, productive working relationships with their QIO," Parkinson said. "Attempting to recreate these relationships with an organization operating several states away dismantles the progress the profession has made, and takes precious time and resources away from a currently beneficial system."
Parkinson said that federally funded but locally based QIOs work closely with local providers, consumers and stakeholders across the continuum of care in every state to ensure patient safety, adopt best clinical practices and improve systems of healthcare delivery.
QIO advocates point to a study in The Journal of the American Medical Associationthis year that found a 6% drop in both hospitalizations and readmissions among Medicare recipients because of the work of QIOs in 14 pilot communities.
The study found that targeted improvements facilitate care transitions and improve coordination as patients moved from one care setting to another. As a result, QIOs helped prevent about 6,800 hospitalizations and 1,800 readmissions per year. Advocates said that return visits are avoidable, yet cost the federal government billions of dollars each year, while funding the work of QIOs costs less than a dollar a month per Medicare beneficiary.
"While this CMS-funded work focuses on the quality of care provided to our nation's seniors, the program's learnings and successes to-date improve the care provided to Americans of all ages," said Adrienne Mims, MD, MPH, president of AHQA and medical director of Atlanta-based Alliant GMCF, the QIO for Georgia.
"Anyone who has ever been or will be a patient benefits, but we need to maintain the existing local infrastructure if we're to ensure the program continues to meet patients' unique needs, which can vary considerably from state to state. There's no evidence to show that a regional model will achieve better or even equivalent outcomes for patients."
AARP has also warned CMS against significant changes to the QIO program without first evaluating the proposed new approaches through pilot or demonstration programs to ensure there are no negative, unintended consequences.
The not-for-profit healthcare sector will likely see softening median ratios in 2013, says a Standard & Poor's Rating Services analyst. With many efficiencies already factored into healthcare system operations, additional savings may be difficult to realize.
Not-for-profit hospitals and healthcare systems struck a careful balance in 2012 with improved operational efficiencies that offset growing costs, lower volumes, and other financial pressures. However, that balance may be harder to sustain in 2013 and beyond, Standard & Poor's Rating Services says.
With that in mind, S&P analyst Kenneth T. Gacka says the not-for-profit healthcare sector will likely see weakened median ratios in 2013 in the face of those continuing and growing incremental pressures that include healthcare reform.
"The 2012 medians reflect a continuation of the peak in metrics reached in 2011, but we expect ratios to soften gradually in the next one to two years as incremental pressures persist and even intensify amid industry changes related to healthcare reform," Gacka says.
Gacka says many of the 144 health systems and 409 stand-alone providers rated by S&P over the past few years have undertaken many of the standard belt-tightening measures that have been seen across the healthcare sector, especially around staffing.
"Some places have had reductions in force, or they're not filling vacant positions, or there is a real focus on full time employee management and making sure that hospitals are efficiently flexing their variable staff to volume trends. Those aren't really new to the healthcare industry. Folks have been doing that for a long time and continue to do that… in addition to some of the non-salary things like renegotiating your supply contracts or different vendor contracts."
With many of those efficiencies already cooked into hospital operations, Gacka says additional savings may be more difficult to realize.
"From our perspective in discussions with management, this has been going on for a number of years so you get to the point of how much longer you can take those things. Some of the low-hanging fruit is picked so it gets to the next level of additional efficiencies," he says.
"In a lot of our discussions with management they recognize that and they are looking to really getting lean methodologies implemented in operations as well as looking for cutting the fat from the systems in terms of clinical variations, differences in practice, to get the harder-to-get structural savings out of the organizations."
Some stand-alone providers in particular are experiencing weakening financial operating performance even in the face of revenue growth, a trend that S&P believes will be exacerbated with further declines in utilization, smaller rate increase for services, and continued investment in technology and physician compensation.
In such an environment, Gacka says he expects to see continued mergers and acquisitions in the not-for-profit hospital sector.
"You have a number of forces driving that," he says. "One being the traditional benefit that you think of in terms of economies of scale, better negotiating clout and being able to fixed costs over a bigger revenue base; another is that as organizations prepare for the evolving healthcare environment, you have the push toward population health management and also growing vertically to give organizations that experience in managing the whole continuum of care, whether that be adding an insurance plan to get experience with risk."
S&P analyst Martin D. Arrick says he doesn't see things getting better in the not-for-profit hospital sector even if the 2% Medicare cuts mandated by sequestration is eventually resolved.
"There are so many forces. We call them 'various incremental pressures' but the key word is 'incremental.' Each one by itself is not the main driver, but taken together they are forcing the direction," he says. "There is probably no one single thing if it gets reversed like the sequester that will change the fortunes of the broad sector and where it is going."
"We are constantly on the lookout for stuff, but our view is that Medicare and government reimbursements are going to continue to be tight for an extended period of time. A sequester is part of that but annual update factors are a part of that, a broad movement to limit disproportionate share funding is part of that," Arrick says.
"If you said every single government action gets reversed and we are going back to 3% rate increases, no sequester, bumper cash flows for DSH, that would be a lot of things going in the right direction. That is a big plus. If one thing gets turned around it's great, people will be happy that one little piece of the cuts get changed. But no one thing changes the bigger picture that we expect overall performance to be compressed."
CMS is asking for public input on whether or not physicians have a privacy interest with their Medicare payments. If they do, CMS says it wants to create a review system that balances a physician's privacy with the public interest.
Now that Medicare payment data for individual physicians is no longer sealed from public view, the Centers for Medicare & Medicaid Services wants help building appropriate policies that balance transparency and access to the data with privacy protections for physicians.
A federal judge in May lifted an injunction in place since 1979 that prohibited CMS from disclosing Medicare payments to physicians. The ruling overturns a policy to protect physicians' privacy, which federal officials had installed at the behest of the American Medical Association.
"In light of this recent legal development and our ongoing commitment to greater transparency in the health care system, CMS seeks public input on the most appropriate policies with respect to disclosure of individual physician payment data," the agency said in an Aug. 6 request-for-public-comment notice.
Currently when the news media or other outside parties request annual Medicare payment data on individual physicians, CMS responds that it will have to provide the data under the Freedom of Information Act unless an exemption applies.
"In this case, since physician information is covered by the Privacy Act, we look at whether such disclosure may constitute a clearly unwarranted invasion of personal privacy by weighing whether the public interest in disclosure outweighs the physician's privacy interest in the information," CMS said.
"It is important to note that CMS is not considering public disclosure of any information that could directly or indirectly reveal patient-identifiable information. CMS is committed to protecting the privacy of Medicare beneficiaries."
CMS noted that the move toward greater transparency has gained considerable momentum in the 33 years since the injunction was put in place, driven by the substantial growth in the size of Medicare both in total cost and as a portion of the federal budget, and by public outcry over the fraud, abuse and waste in the program.
In addition, the Affordable Care Act allows CMS to provide Medicare claims data to some entities for the production of publicly available performance reviews.
"Since 2010, CMS has released an unprecedented amount of aggregated data in machine-readable form," CMS said. "These data range from previously unpublished statistics on Medicare spending, utilization, and quality at the state, hospital referral region, and county level, to detailed information on the quality performance of hospitals, nursing homes, and other providers.
In May 2013, CMS released information on the average charges for the 100 most common inpatient services at more than 3,000 hospitals nationwide, followed in June with the release of average charges for 30 selected outpatient procedures."
In its request-for-comment notice, CMS is asking for public input on whether or not physicians have a privacy interest with their Medicare payments. If they do, CMS says it wants to create a review system that balances a physician's privacy with the public interest.
CMS also wants suggestions on specific policies it should consider regarding the disclosure of individual physician payment data "that will further the goals of improving the quality and value of care, enhancing access and availability of CMS data, increasing transparency in government, and reducing fraud, waste, and abuse within CMS programs."
CMS also wants suggestions for how it should release information about individual physician payments, such as through line item claims details, or aggregated data at the individual physician level.
Remarks must be submitted within 30 days of the Aug. 6 notice.
The lessons learned about population health management and the value of medical homes and coordinated care come straight from the nation's community health centers, which celebrate nearly 50 years of providing healthcare access.
Lindsay C. Farrell, President/CEO
Open Door Family Medical Center
If imitation is the sincerest form of flattery, then next week we should forgive the healthcare professionals serving the working poor and vulnerable populations at the 1,128 or so community health centers across the nation who might suffer a well-deserved swell of pride for the job they do.
August 11 marks the start of National Health Center Week 2013. After nearly 50 years of providing access to care for a generally sicker demographic of lower-income people in often medically underserved areas, the lessons learned at community health centers about population health management, and the value of medical homes and their coordinated and follow-up care are being replicated across the nation as other provider venues serving more-affluent patients cope with the move towards value-based reimbursements and a post-fee-for-service world.
"I have to say that we really have some capabilities that the marketplace really needs now and will need into the future. We were doing population health 10 years ago," says Lindsay C. Farrell, president/CEO of Open Door Family Medical Center. The nonprofit center has a $34 million annual budget and operates five clinics and five school-based programs that serve about 40,000 people in the Ossining, NY area.
"Population health is a relatively new term out there and it's been a term of art as a result of Accountable Care Organizations. But the feds were making us do it a long time ago because they wanted to make sure we were delivering value for the dollars they were investing. Those skills are important in our entire approach to patients and that is what the marketplace wants today so I have to believe that is going to serve us well in the future."
Farrell says community health centers are key institutions in the communities they serve because they not only provide proactive and preventative care, they teach wellness. "We are focused on prevention," she says. "We realize that a prescription might not necessarily be the be all and end all, that very often it is lifestyles and behaviors that have the most significant impact on health."
"That is not to say we don't write a lot of prescriptions over the course of the day, but we try to do more than that. We realize that life isn't about quick fixes. Rather, being healthy takes effort over time, and so we like to partner with our staff and our patients and their families that rely on us so that we can all be a little healthier.
The National Association of Community Health Centers estimates that the nation's health centers serve about 22 million people each year, and save about $24 billion by providing proactive and preventative primary care for low-income and uninsured people that keeps them out of the emergency room. In addition to primary care, community health centers often provide behavioral health services, dental health services, pharmacy, wellness and nutrition programs, and health counselors for their patients.
"We are cost effective because we are primary care providers and our job is to keep people healthy and out of the hospital. That is our primary focus," Farrell says.
"Also, our patients don't have a lot of money and we have a lot of uninsured patients, so that impacts the way we practice. If you have a patient who doesn't have insurance coverage, you are not going to be ordering a gazillion lab tests or diagnostic studies because the patients just can't afford it. You are going to be a bit more cautious because our patients can't have it all when they want it. That is actually not such a bad thing because there is a lot of literature that suggests that an overuse of the healthcare system doesn't necessarily make you healthier or happier."
Follow-up care coordinated by health counselors plays a big part in the success at Open Door. "There are lots of follow-up calls or face-to-face meetings to make sure that they got their medication and that they're taking the medication and that they can afford their medication. Do they know how to test their blood sugar? Can they afford the types of foods that they should be eating?" Farrell says. "We have classes and facilities outside of the exam room so that is how we are a little different than more traditional physician practices."
Unlike community health centers in rural areas, which serve a wider socio-economic demographic because they're often the only care provider in town, Farrell says Open Door's patients are largely working poor people, mostly Latinos, who have no other affordable venues in a part of the nation that is otherwise teeming with providers.
"We are in suburban New York and if anything, we are over-doctored and over-hospital bedded here," she says. "Isn't it fascinating that despite that federally qualified health centers still need to exist because our patients couldn't get served in the traditional setting? You wish that physician practices and hospitals could be accommodating, but the fact is that they aren't and that is why we needed to be here."
NACHC's Amy Simmons Farber says more than 1,000 events are planned next week under the theme of Transforming Health Care in Our Local CommunitiesCommunity health centers across the nation will host dignitaries and the public and members of Congress enjoying their well-earned five-week recess will be invited to learn about the unique services the centers provide and the impressive track record compiled while delivering nearly 50 years of value-based and coordinated care.
"Health centers go beyond the reach of traditional primary care and offer a number of other services that don't just focus on preventing illness but also looking at the factors that cause illness, such as nutrition, housing and unemployment," Simmons Farber says.
Community health centers are actually one of the few venues that command bipartisan support in the otherwise dysfunctional Congress. With about 39% of the programs funded through Medicaid and federal grants, community health centers avoided the impact of the 2% Medicare cuts mandated by sequestration.
"In fact we got more money," Farrell says. "That shows you how great our folks are and it also shows you how much Congress likes the work we are doing. We get results. We are very judicious about our resources. We are lucky that the feds have been as generous as they have been of late but that hasn't been the way it's always been over the last 30 years. We operate on the premise that dollars are scarce and precious and we have to utilize them for the greatest impact."
No clear reason or firm date was given for Farzad Mostashari's plan to exit the Office of the National Coordinator. His unexpected move comes at a critical time as HHS grapples with complex issues over the implementation of Meaningful Use Stage 2.
Farzad Mostashari, MD, ScM
National Coordinator for Health Information Technology
The physician leading the federal government's sweeping and aggressive efforts to implement healthcare information technology has announced that he will leave the job this fall.
After four years at the Office of the National Coordinator for Health Information Technology and leading the office since 2011, Farzad Mostashari, MD, ScM, made the unexpected announcement Tuesday in a letter to colleagues.
"It is difficult for me to announce that I am leaving. I don't know what I will be doing after I leave public service, but be assured that I will be by your side as we continue to battle for healthcare transformation, cheering you on," Mostashari wrote.
He declined to say why he was leaving and did not say what he planned to do after leaving the office. Officials at HHS declined to comment on the reasons for his departure.
Health and Human Services Secretary Kathleen Sebelius issued a statement praising Mostashari's tenure as a "time of great accomplishment."
"Farzad has been an important advisor to me and many of us across the Department. His expertise, enthusiasm and commitment to innovation and health IT will surely be missed. In the short term, he will continue to serve in this role while a search is underway for a replacement," Sebelius said.
While no firm date for Mostashari's last day at ONC was given beyond "the fall," his departure comes at a critical time as HHS grapples with complex issues and grumbling from providers over the implementation of Meaningful Use Stage 2, which goes into effect for hospitals on Oct. 1, and on Jan. 1, 2014 for physicians. The American Hospital Association and the American Medical Association have asked Sebelius to roll back the implementation dates.
Mostashari confirmed via Twitter on Tuesday his intention to leave ONC
Mostashari has resisted calls to roll back the implementation date. He is the lead author in a study published this week in Health Affairs which shows that health information exchanges between hospitals and other providers jumped 41% from 2008 to 2012. The study examined national surveys and found that six in 10 hospitals routinely swapped electronic health information with providers and hospitals beyond their walls in 2012.
"We know that the exchange of health information is integral to the ongoing efforts to transform the nation's health care system and we will continue to see that grow as more hospitals and other providers adopt and use health IT to improve patient health and care," Mostashari said in remarks accompanying the study. "Our new research is crystal clear: health information exchange is happening and it is growing. But we still have a long road ahead toward universal interoperability."
With Mostashari leaving, it's not clear if HHS will reconsider rolling back the implementation dates.
In his letter Tuesday to colleagues, Mostashari conceded that "there are formidable challenges still ahead for our community, and for ONC. But none more difficult than what we have already accomplished. In these difficult and challenging times, your work gives us hope that we can still do big things as a country. That government and the private sector working together can do what neither can do alone. We have been pioneers in a new landscape, but that landscape is one changed forever, and for better."
As news of Mostashari's departure spread Tuesday, the paeans rolled in.
"Through Dr. Farzad Mostashari's leadership, we saw the Office of the National Coordinator lead our nation's providers through the first gates of measured, meaningful use of electronic health records, and address in reality those initial standards that make our health information portable across the U.S. healthcare system," College of Healthcare Information Management Executives President/CEO Russell P. Branzell and Chairman George T. Hickman said in a joint statement.
American Hospital Association senior vice president of policy Linda Fishman issued a statement saying: "We appreciate the hard work of Dr. Mostashari in supporting the adoption of electronic health records and working toward our shared vision. America's hospitals are on a pathway toward a reformed health system that is supported by the use of EHRs. We wish him the best of luck in his next endeavor and we will continue to work collaboratively with HHS to realize our shared vision."
Six in 10 hospitals routinely swapped electronic health information with healthcare providers and health systems beyond their walls in 2012, says a study from the Office of the National Coordinator for Health Information Technology.
Health information exchanges between hospitals and other providers jumped 41% from 2008 to 2012, according to federal government research published this week in Health Affairs.
The study, led by National Coordinator for Health Information Technology, Farzad Mostashari, MD, examined national surveys and found that six in 10 hospitals routinely swapped electronic health information with providers and hospitals beyond their walls in 2012.
"EHR adoption and HIE participation were associated with significantly greater hospital exchange activity, but exchanges with providers outside the organization and exchanges of clinical care summaries and medication lists remained limited," the study said.
"New and ongoing policy initiatives and payment reforms may accelerate the electronic exchange of health information by creating new data exchange options, defining standards for interoperability, and creating payment incentives for information sharing across organizational boundaries."
Mostashari said research suggests that EHRs and HIEs are complementary tools used to enable health information exchange. Stage 2 Meaningful Use, which requires hospitals to exchange data with outside organizations using different EHRs, and to share summary of care records during transitions of care, can accelerate hospital use of HIE to enhance care quality and safety.
"We know that the exchange of health information is integral to the ongoing efforts to transform the nation's health care system and we will continue to see that grow as more hospitals and other providers adopt and use health IT to improve patient health and care," Mostashari said in prepared remarks. "Our new research is crystal clear: health information exchange is happening and it is growing. But we still have a long road ahead toward universal interoperability."
It's not clear if the government-sponsored research will assuage the misgivings of leading provider organizations that have asked the federal government to dial back the implementation dates for hospital Stage 2 Meaningful Use, which go into effect on Oct. 1 for hospitals and on Jan. 1, 2014 for physicians. Last month the American Hospital Association and the American Medical Association sent a joint letter to Health and Human Services Secretary Kathleen Sebelius telling her the requirements for Stage 2 MU were "overlyburdensome."
"Our members, and the vendors they work with, report growing concerns that the rapidly approaching start date for Stage 2 is on a trajectory that will not provide enough time or adequate flexibility for a safe and orderly transition unless certain changes are made," AHA President/CEO Rich Umbdenstock and AMA CEO James. L Madara, MD, said in the letter.
"As of July 17, the official federal list of certified vendor products shows only nine complete 2014 Edition certified EHRs for the inpatient setting, produced by only six vendors. By comparison, the list shows 313 complete 2011 Edition certified inpatient EHRs. On the ambulatory side, only 11 complete 2014 Edition certified EHRs are listed, while about 1,300 were certified for 2011."
The Office of the National Coordinator for Health Information Technology study found that:
58% of hospitals exchanged data with providers outside their organization in 2012 and hospitals' exchanges with other hospitals outside their organization more than doubled during the study period.
Hospitals with basic EHR systems and participating in HIEs had the highest rates of hospital exchange activity in 2012, regardless of the organizational affiliation of the provider exchanging data or the type of clinical information exchanged.
The proportion of hospitals that adopted at least a basic EHR and participated in an HIE grew more than fivefold from 2008 to 2012.
Between 2008 and 2012, there were significant increases in the percent of hospitals exchanging radiology reports, laboratory results, clinical care summaries, and medication lists with hospitals and providers outside of their organization.
84% of hospitals that adopted an EHR and participated in a regional HIE exchanged information with providers outside their organization.
Mostashari said more research is needed for care summaries and medication lists because only about one-third of hospitals exchanged clinical care summaries or medication lists with outside providers.
Preliminary data from the Bureau of Labor Statistics marks July as the third month this year in which the hospital sector lost jobs. But one analyst is not ready to call it a trend.
With 2013 more than halfway completed, new federal data shows that hospital job growth has slowed considerably.
Caroline Steinberg, vice president, Health Trends Analysis at the American Hospital Association says the 2% cuts to Medicare mandated under the federal budget cuts known as sequestration are to blame.
"Medicare represents more than 40% of the care provided by hospitals and when you just lop off 2% of that, it's a big impact on hospitals," she says. "They have to provide the same amount of care they were providing before, but now instead of getting paid 92 cents on the dollar it's closer to 89 cents on the dollar. They were already losing money on Medicare and this makes it worse."
Bureau of Labor Statistics preliminary data marks July as the third month this year in which the hospital sector lost jobs, with 4,400 fewer jobs in July than in June. Since January, hospitals have created 1,700 new jobs. In the first seven months of 2012, hospitals created 38,600 jobs.
The larger healthcare sector, which includes hospitals, nursing homes, ambulatory surgery centers, clinics, and physicians offices, created a mere 2,500 jobs in July, well below the monthly average of 15,700 new jobs in the first seven months of 2013. The 2013 monthly average is well below the 24,300 new jobs that healthcare averaged in the first seven months of 2012. BLS figures for June and July are preliminary and can be subject to considerable revision.
Steinberg says most hospitals are trying to soften the blow of sequestration by first shedding administrative jobs to protect caregivers and patient services. "But when the rubber hits the road they start to cut programs and those programs that lose the most money are the first to go, things like psychiatric care, post-acute care, home health programs," she says. "You really do begin to see access suffering."
The across-the-board cleaver cuts mandated by the sequestration will lop $1.2 trillion off the federal budget over the next nine years, averaging more than $109 billion each year. This includes $11 billion in Medicare funding in 2013 in the form of the 2% reimbursement cuts.
Nicole Smith, a senior economist at the Georgetown University Center on Education and the Workforce, agreed that sequestration is playing a role in the slower job growth for healthcare, but she says it's too early to call it a trend.
"Because healthcare job growth as a whole has been strong for so long I am just really reluctant to look at two to three months in a year and call this a pattern of decline," she says. "Healthcare is one of the few sectors that even in the height of the recession continued to add jobs. Maybe we are observing a little correcting of the market. I don't think three or four months is enough of a trend to discredit the other six or seven years of growth."
The loss of hospital jobs in July was offset by the 6,600 jobs created in the ambulatory care sector. But even that job growth is down somewhat when compared with 2012. Ambulatory services created 100,700 jobs so far in 2013, an average of 14,300 per month. In 2013 ambulatory services created 108,300 jobs, an average of 15,400 per month.
Steinberg says the AHA will continue to press Congress and the Obama administration to find an alternative to the sequestration cuts. Until then, she says, hospitals will likely continue to cut services and staff, and cities and towns across the nation will feel the adverse effect for both access to care and local economies.
"Healthcare has always been an economic engine. The jobs tend to be high-quality jobs with good benefits. They tend to be, relative to the service sector, a little higher-paying. It's bad for the economy when hospitals cannot continue their contributions," she says.
Even with the slower job growth, Smith remains bullish on the job growth prospects healthcare sector. "Despite all of these short-term adjustments we have to make to the industry our forecasts still show healthcare as being a robust and buoyant sector over the next couple of years," she says. "Not only will it continue to grow. It continues to upscale. The newer entrants will certainly look different in terms of the credentials they hold compared to the existing workers who are there now."
More than 14.5 million people worked in the healthcare sector in July, with more than 4.8 million of those jobs at hospitals and more than 6.5 million jobs in ambulatory services.
In the larger economy, nonfarm payroll employment rose by 162,000 in July, with most of the new jobs coming in retail sales, food service, financial activities, and wholesale trade. The unemployment rate fell slightly to 7.4%, BLS reports.
Even with the modest gains, BLS said 11.5 million people were unemployed in July, a slight improvement from June. The number of long-term unemployed, defined as those who have been jobless for 27 weeks or longer, fell slightly to 4.2 million people in July who represented 37% of the unemployed.
