HCA and Tampa-based USF Health announced they are forming a statewide trauma network to improve trauma care and centralize research in Florida.
About 38% of trauma patients in Florida receive treatment in a designated trauma center, below both the national average and the state’s goal to have 65% of trauma patients treated in a Florida licensed trauma center, HCA and USF Health said in a joint announcement.
“Getting a patient to a trauma center within the first hour of injury, or golden hour, drastically increases their chance of survival,” says Jonathan Perlin, MD, president of clinical services and CMO for HCA. “Research supported by the Centers for Disease Control shows trauma mortality is reduced when a seriously injured patient is treated at a trauma center versus a non-trauma hospital.”
In Florida, the leading cause of trauma injury is motor vehicle crashes, accounting for 43% of all injuries in 2008. Motor vehicle injury fatalities are strongly associated with the distance from a trauma center to the accident scene, according to the study A Comprehensive Assessment of the Florida Trauma Center, conducted by USF and UF for the Florida Department of Health. The study also notes that counties without trauma centers have higher mortality rates.
“It is absolutely critical that we expand access to trauma care to state-designated trauma service areas not currently being served,” Perlin says. “Trauma centers deliver superior outcomes for their patients and we are excited to have USF join us as we work to improve the access to quality trauma care in Florida.”
Five HCA hospitals across Florida and the University of South Florida College of Medicine will affiliate to create the Florida Trauma Research and Analysis Center, TRAC, a centralized statewide data collection for trauma research and coordination of services. TRAC’s focus on quality patient care and research will improve trauma care in the state, said Stephen Klasko, MD, dean of the USF College of Medicine and CEO of USF Health.
“Our goal is to have Florida be the safest state in the nation,” Klasko says. “This network will provide the state’s trauma patients with consistent and state-of-the-art care.”
David J. Smith Jr., MD, chair of the USF Department of Surgery, says TRAC data from five hospitals will identify trends that might not be noticed at one hospital. “Florida TRAC will help doctors learn how to better treat trauma patients, whether they are injured in car crashes or suffering from heart attacks,” Smith says.
USF will name a chief trauma medical director to oversee the network and appoint a medical director of trauma at each hospital, as well as helping to recruit needed specialists.
The five HCA hospitals are:
Blake Medical Center, in Manatee County;
Kendall Regional Medical Center, in Miami-Dade County;
Lawnwood Medical Center, in St Lucie County;
Orange Park Medical Center, in Clay County;
Regional Medical Center Bayonet Point, in Pasco County.
All of the hospitals have applied for Level II Trauma Center designation. Lawnwood is approved and operating, and the other four hospitals are in the application process.
Using automated external defibrillators in hospitals on patients with sudden cardiac arrest is ineffective and potentially harmful when compared with traditional defibrillators, according to study in the Journal of the American Medical Association.
The study, led by cardiologist Paul Chan, MD, at Kansas City-based Saint Luke's Mid America Heart and Vascular Institute, examined data from the National Registry of Cardiopulmonary Resuscitation of 11,695 hospitalized patients with cardiac arrest between Jan. 1, 2000, and Aug. 26, 2008, at 204 hospitals following the introduction of AEDs on general hospital wards.
AEDs diagnose sudden cardiac arrest, judge whether defibrillation is needed, and deliver an electrical shock to restore the heart's normal rhythm. For cardiac arrest patients who respond to a defibrillation shock (19% of the study's population) there was no difference in rates of survival between those treated by an AED or a conventional defibrillator.
"It was a disappointing finding," Chan says.
In some circumstances, use of AEDs in the hospital was associated with higher death rates.
"For the majority (81%) of the cardiac arrests which do not respond to defibrillation, the use of AEDs to assess the initial rhythm in patients with cardiac arrest was associated with lower survival than with a conventional defibrillator," Chan says.
While AEDs have improved survival in out-of-hospital settings such as schools, airports, and sporting events, data on their effectiveness in hospitals—where they're increasingly used—is limited.
The findings seem surprising, Chan says, but they make sense. "Because these cardiac arrest rhythms are not treatable by defibrillation, assessment with an AED should not result in any benefit. But given that an AED takes a much longer time to assess a rhythm than a medical provider with a conventional defibrillator, their use likely deprives a cardiac arrest patient with a non-shockable rhythm of critical CPR time during the initial minutes, when perfusion to their organs (brain, liver, kidneys) is paramount. That delay may be hurting the patient, and explains why AEDs may have been associated with lower in-hospital survival."
Chan adds that the use of AEDs in public settings, however, remains essential.
"Although our study found that an AED does not appear to be useful in the hospital setting, that does not mean that an AED is not useful outside the hospital, especially in public places," Chan said. "Because hospitals are equipped with staff that can perform CPR effectively, shock patients when needed, and give important cardiac arrest medications, the benefits of AEDs in a hospital may be harder to realize than outside the hospital."
The research concludes that hospitals relying on AEDs should reconsider treatment approaches.
"Our institutional CPR committee has struggled with what to tell the first person who responds to the bedside of a patient in cardiac arrest," says Steven Kronick, MD, assistant clinical professor of emergency medicine and director of advanced cardiac life support at the University of Michigan Health System, whose investigators helped research the study.
"This study supports that continuous chest compressions should be provided immediately and without interruption until the cardiac arrest rhythm can be determined. It also shows that in the hospital setting, rhythm identification should be done by the medical provider rather than by the AED, where delays in rhythm analysis can be significant," Kronick said.
More than 50,000 AEDs have been purchased by hospitals alone since 2005.
"Time to defibrillation is an important quality metric, but there has been no silver bullet to achieve shorter times to treatment to date," Chan says. "AEDs have been touted as a logical solution, and hospitals are buying these in increasing quantities. But, they do not appear to improve survival. In order to improve the quality of in-hospital resuscitation, we need to go back to the drawing board and do the hard work to identify innovative strategies to improve survival for cardiac arrest patients."
Despite all the ululating about shrinking reimbursements and the impact of federal healthcare reform, and any of a number of financial icebergs out there, let's acknowledge that it's good to be in healthcare.
Numerous surveys show that physicians, highly skilled clinicians, and healthcare executives in the United States are the most highly compensated class of workers on the planet. Physicians held the top six positions for median pay in Money magazine's Best Jobs in America survey. Nurse anesthetists were ranked No. 7, with a median salary of $156,000.
New survey results from Executive Compensation 2010/2011* show that hospital CEOs earn an average $353,900 per year, (CEOs at not-for-profits average $225,400). CEOs at homecare facilities average $282,300 a year, CEOs at physician clinics average $254,000. CEOs at behavioral health facilities average $241,300, and CEOs at long-term care facilities average $235,700.)
There are regional variations in salary but everybody seems to be doing all right. Hospital administrators in the Northeast average the highest base salary, $247,900 per year, followed by those in the West, $226,100. The Southeast is $213,300, South Central is $192,000 per year, and the Midwest is $152,600.
As a broad and vaguely defined category, "healthcare industry presidents" earn the highest average base salary, $296,400, of any industry in the overall economy, followed by the insurance industry, with an average base salary of $290,700, the Executive Compensation survey finds.
EC's survey found that "while pay increase budgets for the healthcare industry have steadily decreased since the onset of the recession in 2007, salaries for many executive positions have continued to rise."
CIOs, for example, have seen their pay increase by 10.5% over the last three years, an average of $193,000 in the healthcare sector, and $200,100 at hospitals. CEOs, on the other hand, have seen their pay reduced by nearly 20% since 2007, while the average base salary for COOs has dropped 9% to $225,500 in healthcare and $245,100 at hospitals.
These executives, physicians, and skilled clinicians undoubtedly would make a strong argument that they deserve the salaries they're getting. Besides, it's what the market is paying, a lot of them work well beyond a 40-hour week, and it's hard to blame anyone for earning as much money as they can.
However, let's put this in perspective. According to the U.S. Census Bureau, 4.1% of U.S. households had an income between $150,000 and $200,000 in 2009, and 3.9% had an income of $200,000 or higher, while 11% of U.S. households earn between $15,000-$25,0000 annually. The median household income in the U.S. that year was $50,221.
These relatively high salaries in the higher echelons of healthcare probably are not driving up the cost of healthcare, which accounts for about $2.2 trillion annually. It's hard to see that salaries could dramatically affect a number that big.
However, it does raise questions about perspective, because people in positions of relative wealth and influence are setting policies and pricing services for people who aren't. Can that 3.9% of households that make $200,000 understand the financial constraints on that 11% of households earning $15,000-$25,000? For those earning $250,000 a year, $100 for an office visit, or $1,000 or $5,000 for a health insurance deductible may seem reasonable. If you're earning $25,000 a year, however, that can be healthcare denied.
"Cost containment" in healthcare means shifting more costs onto the backs of patients, about 90% of whom who earn considerably less than physicians and hospital executives. Studies consistently show that healthcare inflation is relatively constant, at about 7% or so every year—often double or triple the Consumer Price Index—in boom times and in busts.
Maureen Maitland, vice president of Standard & Poor's Indices, attributes the rise in healthcare costs to supply and demand; healthcare providers are charging more because they can. "Basically the demand for healthcare is high, and physicians and hospitals are trying to meet their budgets, and are able to put these rate increases through," she said.
This is unsustainable. More and more, middle class Americans are feeling the pinch of rising health insurance premiums in an era of stagnant wages. So far, public scorn and blame has been directed almost entirely at the health insurance industry. That will change, however, as more people look for explanations and scapegoats. The mainstream media will write more stories about compensation for senior executives at hospitals and health systems. Even, doctors—consistently among the most trusted professionals in the United States—may soon find their compensation on the public radar.
Will the criticism be fair? Given the rage out there in the public, it almost doesn't matter. Healthcare is as much an emotional issue as it is an economic issue for many Americans. That was made clear during the healthcare reform debate over the last two years when town hall meetings devolved into screeching matches.
So, as healthcare costs continue to climb, brace yourself for renewed public interest in C-Suite salaries. A lot of people are figuring out what we already know: it's good to be in healthcare.
*Compensation Data Healthcare 2010/2011 contains data on over 200 industry-specific job titles and more than 250 benchmark titles ranging from entry-level to top executives. In 2010, Compdata Surveys received data from nearly 1,200 healthcare organizations across the country, reporting on 5,400 locations, effective Jan. 1, 2010.
The Centers for Medicare & Medicaid Services said it will update its five-star plan ratings in 2011, and use the new metric as the basis for quality bonus payments in a three-year demonstration project for Medicare Advantage health plans that starts in 2012.
The five-star rating system is used by CMS to ensure that health plans meet Medicare quality standards. The ratings allow beneficiaries to compare the quality of care and customer service that Medicare health and drug plans offer.
In addition, a "low performer" icon will be placed next to plans with fewer than three stars for the past three years. CMS' star rating system considers 53 quality measures, including preventive services, managing chronic illness, and keeping consumer complaints to a minimum. All ratings can be found on Medicare's Plan Finder.
The 2011 ratings released Friday will serve as the basis for a quality bonus payment in the demonstration for Medicare Advantage plans beginning in January 2012. The demonstration builds on the quality bonus payments authorized in the Affordable Care Act by providing stronger incentives for plans to improve their performance and accelerate quality improvements. Medicare Advantage plans earning the highest performance rating—five stars—can get bonuses equal to 5%, and all plans with three stars or more will qualify for a bonus payment beginning in 2012.
"The five-star rating system helps people with Medicare make meaningful distinctions between high-performing and low-performing health plans. They also allow plan sponsors to see how they compare to other plans and encourage them to improve care and customer service, so their plans are more attractive to Medicare beneficiaries," said CMS Administrator Donald M. Berwick, MD. "The demonstration rewards high performers more than low performers, creating an incentive for all performers to improve."
CMS also announced on Friday that it has proposed regulations to implement several provisions of the Affordable Care Act in improve Medicare and Medicare Advantage prescription drug programs. They include codifying clarifications to CMS authority to negotiate plan bids, expanding restrictions on charging higher cost-sharing than traditional Medicare for certain services, and limiting long-term care pharmacy waste by specifying efficient dispensing practices.
"For 2011, the vast majority of Medicare beneficiaries who wish to enroll in the Medicare Advantage program will continue to see a wide array of plan choices with stable premiums and benefit levels," said Jonathan Blum, CMS deputy administrator, and director for the Center for Medicare. "The demonstration and proposed rules CMS has announced today continue our commitment to make the program stronger than ever before for our beneficiaries."
More information on this year's current and previous ratings scores is available on a master table at the Federal Register. A link to the proposed rulemaking changes for Medicare drug and health plans cost sharing and bid process can be found here.
The proposed rule has a 60-day public comment period, which closes on Jan. 10. The final rule will be published in early spring 2011.
The cost of healthcare for people with employer-sponsored health insurance climbed 6.3% for the fiscal year ending June 30, with hospital costs outpacing other healthcare-related cost, Thomson Reuters reports.
The Thomson Reuters Healthcare Spending Index for Private Insurance measures historical and current levels of per capita healthcare spending for individuals whose coverage is provided by self-insured employers — about 25% of U.S. healthcare expenditures.
"The index is accurate and detailed because it's based on the healthcare utilization of millions of Americans," said Gary Pickens, chief research officer at the Thomson Reuters Center for Healtchare Analytics, in Ann Arbor, MI. "That allows us to report on cost trends overall and for key components — hospitals, physicians, drugs, and patients' out-of-pocket costs."
Spending for hospital care has increased faster than spending on physician services or prescription medicines in the past year. Hospital costs increased 8.2%, physician costs increased 5.5%, and drug costs increased 3.4%.
Index estimates are based on Thomson Reuters databases of healthcare claims for inpatient and outpatient services. The 2009-10 index represents the real-world treatment patterns and costs of more than 12 million employees and their dependents, Thomson Reuters said.
Shifting specialists' routine follow-up care to primary care physicians in a medical home model under the new federal healthcare reforms could save time, money, and free specialists for more complex patient care. However, the lack of primary care physicians could make such a policy difficult to implement, according to a new study by the University of Michigan Health System.
"I don't think anyone would question that there are too few primary care physicians," says John M. Hollingsworth, MD, an assistant professor of urology at the U-M Medical School, and a lead-author of the study, which appeared in the journal Medical Care. "The issue that came up in our study pertains to the role of specialist physicians in the new 'medical neighborhood.'"
According to the study, specialists spend more than 650,000 work weeks collectively on routine follow-up care for patients with common chronic conditions, such as asthma, diabetes, and lower back pain. Delegating a proportion of this care has the potential to create system-wide efficiencies by freeing specialists to concentrate on new patients and those with complex conditions.
However, redistributing half of the routine follow-up care would require either thousands of new primary care doctors or an extra three weeks of work a year from the primary care physicians in the current workforce, the study found.
"The cumulative time spent by specialists on routine chronic care is not trivial," says the study's senior author David C. Miller, MD, an assistant professor of urology at the U-M Medical School. "As a urologic oncologist, I take care of many cancer survivors. With a detailed care plan constructed by the treating oncologist, much of the follow-up care for these patients could potentially be assumed by a primary care physician-directed medical home, with appropriate referral back to me if problems or questions arise."
The study analyzed data from the 2007 National Ambulatory Medical Care Survey for seven chronic conditions: chronic obstructive pulmonary disease/asthma, low back pain, diabetes mellitus, coronary artery disease/congestive heart failure, chronic kidney disease and depression. Researchers examined the time specialists spent with patients for direct and indirect follow-up care for those conditions.
The study was funded by the Robert Wood Johnson Foundation Clinical Scholars Program and the Agency for Healthcare Research and Quality.
Appalachian Regional Healthcare, Inc. filed notice this week that it will sue the West Virginia Department of Health and Human Resources and subsidiary Bureau for Medical Services for low Medicaid reimbursements that threaten the financial viability of Beckley ARH Hospital.
"We do not take this step lightly but do it to protect our patients," Rocco Massey, CEO of BARH, says. "Medicaid reimbursements have been covering only two-thirds of our costs for providing medical care, so BARH has been suffering a substantial financial loss. These Medicaid rates jeopardize BARH's continued ability to provide medical services to all of its patients.”
In fiscal year 2009, the health system says, the 173-bed, not-for-profit BARH received only $9.9 million for the $14.7 million the hospital spent to treat Medicaid patients. Of the $9.9 million in Medicaid reimbursements, $8.2 million came from federal funds. Of the $1.7 million the state put in that year to match federal funds, $1.4 million came from BARH itself through the Medicaid provider tax the hospital pays. The state put in only about $300,000 of its own funds that year for Medicaid reimbursements for BARH, the health system alleges.
"If the state had put in just $800,000 more, the federal government would have matched it with an additional $4 million," Massey says. "That would have covered BARH's Medicaid deficit in fiscal year 2009."
The West Virginia Department of Health and Human Resources offices were closed on Thursday, Veterans’ Day, so state officials were not available for comment.
BARH's 30-day notice of intent to sue West Virginia's Medicaid program is the second such notice issued recently. Last month, the West Virginia Primary Care Association, representing community health centers, filed a similar notice of intent to sue over inadequate Medicaid reimbursements.
About 22% of BARH's patients are Medicaid beneficiaries, so low reimbursements affect the hospital's ability to operate or make capital expenditures. BARH has little opportunity to shift costs to other payers because 47% of its patients are on Medicare—which pays 90% of costs—and 14% are on other government programs or are considered bad debt or charity cases, the health system says.
"The Bureau for Medical Services is required by statute to set Medicaid rates that are reasonable and adequate to meet costs incurred by efficiently and economically operated hospitals," said Stephen Price, an attorney for Appalachian Regional Healthcare. "The bureau also is required to take into account the situation of hospitals that serve disproportionate numbers of low-income patients."
West Virginia law provides that potential litigants must give 30-day notice before suing the state so that it might be possible to settle issues without litigation. "We hope that state officials will use the next 30 days to revise Medicaid reimbursement rates and raise them to adequate levels so we can avoid legal action, but we are prepared to move forward if we cannot reach agreement," Price said. "We understand the state has limited funds, but state law requires it to pay Medicaid costs. This proposed legal action is similar to actions Appalachian Regional Healthcare has taken successfully in Kentucky."
Appalachian Regional Healthcare, Inc. is a nine-hospital, not-for-profit health system that serves about 350,000 people in eastern Kentucky and southern West Virginia, with 4,700 employees and a network of more than 600 active and courtesy medical staff. ARH provided more than $120 million in uncompensated care for the uninsured and underinsured. With more than 550 employees, Beckley ARH is the third largest employer in Raleigh County in Southern West Virginia, the health system says.
Accountable Care Organizations must be physician-led, patient-centric, and ensure voluntary participation from patients and physicians, including independent practitioners, under the American Medical Association's principles for ACOs.
“The AMA is committed to ensuring physicians in all practice sizes can lead and participate successfully in new models that allow them to provide the best care to their patients,” says AMA President Cecil B. Wilson, MD. “For this to happen, significant barriers must be addressed, including a lack of resources, existing antitrust rules and conflicting federal policies.
The principles were made public at the AMA's semi-annual policy-making meeting.
Wilson wants flexibility for physicians in all practice sizes to participate in ACOs.
Although ACOs and other models of patient care were recently authorized in the new health reform law, existing antitrust and fraud rules can make becoming part of an ACO difficult for physicians, especially those in small practices, AMA says.
The latest AMA Physician Practice survey found that 78% of office-based physicians in the United States work in practices with nine physicians or less. A majority of those are in either solo practices or practices of two to four physicians.
Key provisions of the 13-point set of principles adopted by the AMA include:
Guiding Principle—The goal of an ACO is to increase access to care, improve the quality of care and ensure the efficient delivery of care. Within an ACO, a physician's primary ethical and professional obligation is the well-being and safety of the patient.
ACO Governance—ACOs must be physician-led and encourage an environment of collaboration among physicians. ACOs must be physician-led to ensure that a physician's medical decisions are not based on commercial interests but rather on professional medical judgment that puts patients' interests first.
Physician and patient participation in an ACO should be voluntary. Patient participation in an ACO should be voluntary rather than a mandatory assignment to an ACO by Medicare. Any physician organization or any other entity that creates an ACO must obtain the written consent of each physician to participate in the ACO. Physicians should not be required to join an ACO as a condition of contracting with Medicare, Medicaid or a private payer or being admitted to a hospital medical staff.
The savings and revenues of an ACO should be retained for patient care services and distributed to the ACO participants.
Flexibility in patient referral and antitrust laws. Federal and state anti-kickback and self-referral laws and the federal Civil Monetary Penalties statute should be flexible to allow physicians to collaborate with hospitals in forming ACOs without being employed by the hospitals or ACOs. This is particularly important for physicians in small- and medium-sized practices who may want to remain independent but otherwise integrate and collaborate with other physicians in the ACO.
Fundraisers spent significantly more money in recession-wracked 2009 than in years past, but collected fewer donations for nonprofit hospitals and healthcare systems, according to the Association for Healthcare Philanthropy.
"The recession's impact and duration were felt more strongly in the U.S. than in Canada, where healthcare philanthropy tended to advance slightly or at least hold its own despite lower levels of government support," said William C. McGinly, president/CEO of AHP. "U.S. nonprofit hospitals, however, often struggled just to keep giving levels steady, and some saw declines."
AHP gathered data from 66 institutions across the U.S. and Canada, including community hospitals, academic/ teaching, tertiary and specialty hospitals and healthcare systems. On average, the recession hurt charitable giving to healthcare institutions most severely in the western United States. Across the sample, median return on investment—a measure of fundraising effectiveness—fell 23% in 2009 from $4.63 to $3.57. For cash donations median ROI fell 17% to $3.26.
AHP's benchmarking survey, which measured ROI for 2009, confirmed trends noted in AHP's FY2009 Report on Giving, which examined charitable donations raised by 522 U.S. and Canadian nonprofit hospitals and healthcare systems. The FY2009 Report on Giving found that healthcare philanthropy dipped 11% in the U.S. last year to $7.6 billion while rising 5.2% in Canada to $1.1 billion.
Interestingly, the survey found that physicians and hospital employees donated more money more frequently. Gifts from physicians and physician groups averaged $5,000, up $3,000 from 2008.
Major gifts of at least $10,000 from individuals, corporations and foundations accounted for 55% of all revenue raised by institutions in the benchmarking sample, which was 7% more than in 2008. Annual giving's portion of total revenues was unchanged at 15%, however, costs associated with annual giving efforts soaked up 27% of all fundraising expenses in 2009, compared with 19% in 2008.
Planned giving fell 2% as a portion of 2009's total giving, however, the average planned gift size increased to more than $140,000, up from about $100,000 in the 2008 survey.
"The constant message that shines through the data is that organizations that best survived last year's worsening economy were those who persevered by keeping sufficient staff and resources to maintain well-rounded philanthropic opportunities and programs," McGinly said.
The American Medical Association this week adopted a social media use policy to help physicians protect patient privacy, and physicians' personal and professional reputations.
"Using social media can help physicians create a professional presence online, express their personal views and foster relationships, but it can also create new challenges for the patient-physician relationship," says AMA Board Member Mary Anne McCaffree, MD. "The AMA's new policy outlines a number of considerations physicians should weigh when building or maintaining a presence online."
The new policy encourages physicians to:
Use privacy settings to safeguard personal information on social networking sites.
Monitor their own Internet presence to ensure that the personal and professional information on their own sites and content posted about them by others, is accurate and appropriate.
Maintain appropriate boundaries of the patient-physician relationship when interacting with patients online and ensure patient privacy and confidentiality is maintained.
Consider separating personal and professional content online.
Recognize that actions online and content posted can negatively affect their reputations among patients and colleagues, and may even have consequences for their medical careers.
The policy on professionalism when using social media was adopted this week at AMA's semi-annual policy making meeting in San Diego.
