Thursday's murder-suicide and related gunshot wounding of a physician at Johns Hopkins Hospital in Baltimore provides a horrifying example of violence inside hospital walls.
Unfortunately, it wasn't an isolated incident. Hospital violence is reported almost every day in the media.
Executives at Baton Rouge General Medical Center, for example, are studying the lessons learned from a Sept. 3 domestic violence-related shooting that left one patient and a visitor seriously wounded.
BRGMC COO Edgardo Tenreiro offered a frank assessment of his hospital's response to the shooting, including the flaws.
"The No. 1 thing we learned is we didn't have an appropriate emergency code to notify staff," he says. "The traditional Code White indicates a violent patient. But in cases of an active shooting you don't want to use Code White because staff is going to respond to a Code White. What you want in a situation with a shooter is for staff not to respond, other than security."
BRGMC now refers to shootings as Code Silver, and staff understand that their job is not to backup colleagues, but to ensure that that patients and visitors in their immediate area are safe and locked down. Code Silver also allows employees to provide an explanation for patients and visitors of what could be a stressful situation, with the possibility that they will have to be evacuated, or that heavily armed SWAT police will conduct room-to-room searches.
Second, Tenreiro says make sure your hospital has the ability to establish a mobile emergency command center outside of the hospital, so that you can communicate with employees inside the hospital during a locked down.
"We had to improvise a command center outside on a sidewalk next to the SWAT command," Tenreiro says. "The fact that we didn't have the direct command center communication made it very difficult for us to let folks inside the hospital know the progress that was being made in clearing the hospital."
The mobile command center must have the ability to forward calls to the main command center telephone lines to a designated cell phone, as well as VPN capability to access computer systems remotely.
"The ability to switch the phone and forward to the cell phone, the technology is there and can be easily activated. It just can't be activated the first time you think about it at one in the morning, which is when we thought about it," he says. "You have to have a process in place for that ahead of time so you can activate it automatically."
Tenreiro says it's a good idea to plan potential responses to shootings with police ahead of time, and perhaps run mock drills "You do it on a regulation basis with fire drills, but you never do it for bomb threats or shootings," he says.
It's important that responding police have a familiarity with your hospital. Tenreiro says that many of the police who moonlight at BRGMC as security guards responded to the shooting and guided their SWAT colleagues through the building. "The police need to know the building," he says.
It's also a good idea to have a box of generic ID swipe cards nearby to help police access locked areas of the hospital.
In the aftermath, Tenreiro says BRGMC is providing mental health counselors for staff who may be suffering from post traumatic stress. "One of our staff members who witnessed the whole incident was having some difficulty sleeping. We have a whole mechanism to help and make sure they know that there is help available—that's its normal to ask for it," he says.
There was a lot of talk about installing metal detectors immediately after the shooting, but Tenreiro says he's not sure that is practical. The two hospitals at BRGMC have 88 entrances that provide access to nearly 3 million people each year. "The cost of doing that could be prohibitive. It's not just the metal detectors. It's staffing the metal detectors. Are you going to have them 24/7?" he says. "That is a hospital-by-hospital evaluation. In our case we don't want to convey an image where the hospital is a place that you can't come into."
Tenreiro says he was concerned about the public relations fallout from the shooting, but the hospital issued regular updates to the traditional media, as well as on Twitter, Facebook, and other social media during the shooting and in the immediate aftermath.
The public appears to understand that hospitals aren't to blame for the violence that permeates society, and are just as likely to be crime scenes as any other public area.
"The way we handled it was very appropriate. It was low key but at the same time very reassuring. Folks understood that we had mechanisms in place to deal with this," he says. "It had no effect. In fact, the week after the shooting our census went up. We handled it in a way that allowed the public and the media to react very positively. It had no impact on our business."
The New York City Health and Hospitals Corporation has been awarded two grants totaling $12.8 million for projects that include creating a medical home model for schizophrenics, and renovating facilities to provide more efficient care of diabetics and other chronic care patients.
A $10 million grant for the patient-centered medical home model will coordinate primary care services and behavioral health care for nearly 5,000 patients with schizophrenia within the 11-zip code care coordination zone across Queens, Brooklyn and Lower Manhattan.
HHC will build an IT infrastructure based on the hospitals' existing electronic health records system to allow patient information exchanges among five HHC hospitals and health centers and mental health community-based providers. The information sharing will allow the providers to access clinical information, medication and problem lists, results and referrals. The HHC participating facilities include Elmhurst, Queens and Woodhull Hospitals, Gouverneur Healthcare Services, and Cumberland Diagnostic & Treatment Center.
HHC also received nearly $2.8 million for two construction projects that will reduce excess beds and inpatient services in favor of lower-cost outpatient care. A $900,000 grant awarded to Kings County Hospital Center in Brooklyn will be used to construct a diabetes clinical care suite adjacent to an already existing diabetes resource center. A $1.9 million grant to Woodhull Hospital Center in Brooklyn will help create a Specialty Care Pavilion for chronic disease management, promising an additional 16,000 outpatient visits annually.
The project creates 10 exam rooms for specialty care, new space for clinical support services, a centralized registration area, improved multi-lingual signs providing direction, and a "navigator" to assist patients. Specialty services will include pain management, asthma care, adolescent medicine, dermatology, and surgery. The additional space will allow ultimately for an additional 5,300 specialty visits annually.
Funding for both projects is provided by the New York State Department of Health, and the Dormitory Authority of the State of New York, through the Health Care Efficiency and Affordability Law of New York, and the Federal State Health Reform Partnership.
Annual performance-based incentive plans are growing for physicians in both presence and scale, according to consultants Hay Group's 2010 Physician Compensation Survey.
The survey found that 92% of group-based organizations offer incentive plans to their physicians, up from 75% in 2009.
Physician incentive plans are also being offered by 63% of hospitals this year, as opposed to 51% in 2009. The percentage of integrated health systems offering physician incentive plans remained steady between 2009 and 2010 at 67%. Of the 28 organizations that responded that they had no physician incentive plans, 39% said they were considering them.
"There is safety in numbers, and it has never been truer in healthcare than it is now," says CJ Bolster, national director for Hay Group's healthcare practice. "Integrated health systems have scale and they can offer job security in lieu of having to offer higher incentives. Group practices that are not directly tied to a hospital or system will traverse a bumpier road in the post-reform era, but they will continue to attract physicians with an entrepreneurial drive and an acceptance of risk."
The incentive plans are also increasingly tied to performance measures, with patient satisfaction and quality the leading factors for all surveyed organizations. Fifty percent of group-based practices tie incentives to patient satisfaction and quality; that percentage is slightly lower for hospital-based (43%) and IHS-based (46%) organizations.
"No one should be surprised that healthcare organizations are moving to link pay to performance," says Ron Seifert, executive compensation practice leader for Hay Group's healthcare practice. "Hospitals will increasingly be rated on performance metrics such as patient satisfaction, readmissions and clinical outcomes, and reimbursements are likely to be linked to these as well. Financially, it's in an organization's best interest to embrace these changes now, rather than waiting for all the reform dust to settle. Communally, a hospital focusing on the needs and health of patients is good for everyone."
Incentive bonuses typically supplement base salaries, which are holding flat in hospital-based organizations, with 2.8% increases in 2009-2010, and 2.9% planned increases for 2010-2011. Group-based physician practices offer higher salary increases (4.8% granted in 2009-2010), but the planned base salary increases for 2010-2011 dropped to 3.3%.
Salary structures and salary planning for physicians remain flexible in 2010, respondents show. Half of hospitals and IHS', and 54% of group-based physician practices, say that their process is independent, meaning that they have a philosophy and structure, but that positions, specialties, departments and specific doctors are reviewed individually for their salary potential and subsequent increases.
The 2010 survey participants included integrated health systems, hospitals and group based physician practices, and covers 128 physician specialties, including 40 pediatric specialties, 16 non-physician provider positions, and 13 medical directors.
The Hay Group survey findings are consistent with a study by the Medical Group Management Association and the Society of Hospital Medicine last week which showed that base salary impacts both productivity and overall compensation for hospitalists.
According to the study, State of Hospital Medicine: 2010 Report Based on 2009 Data, hospitalists who receive a lower proportion of total compensation paid as base salary tend to be high producers who are incentivized to earn more.
The report—which contains information on 443 hospital medicine groups and 4,211 hospitalists—found that hospitalists who received 50% or less of their compensation as fixed base salary reported the highest median work relative value units (wRVUs) at 5,407. Hospitalists who received 51% to 70% of their compensation as base salary performed 4,591 wRVUs, compared to 3,859 wRVUs for hospitalists who received 71% to 90% of their compensation as base salary. Hospitalists who received 91% to 100% of their compensation as base salary reported 3,571 wRVUs.
The Department of Health and Human Services will send $31 million to 10 communities in eight states, and the South Carolina Health Department, for programs to reduce obesity and smoking, increase physical activity, and improve nutrition.
The awards funded by the Prevention and Public Health Fund included in the Affordable Care Act are part of HHS' Communities Putting Prevention to Work program, administered by the Centers for Disease Control and Prevention.
"As I’ve seen throughout the year in my work with Let’s Move!, prevention works when it comes to improving the health of our families," First Lady Michelle Obama said in an HHS statement. "These critical investments will help more communities across America tackle serious health challenges like childhood obesity, while promoting physical activity and healthy eating."
This week’s announcement follows the release in February and March of more than $491.8 million in Communities Putting Prevention to Work funds to states, territories and communities. Those projects are supporting statewide and community-based policy and environmental changes in nutrition, physical activity, tobacco control, and tobacco cessation media campaigns.
“To realize our goals of improving the health of Americans and lowering our nation’s healthcare costs, we must address the underlying factors that influence our families’ health—factors like the foods we eat and the conditions that exist in our homes, neighborhoods and workplaces,” said HHS Secretary Kathleen Sebelius.
These Communities Putting Prevention to Work awards will provide communities with the resources to create healthy choices for residents, such as increasing access to healthy foods, improving access to safe places for physical activity, discouraging tobacco use, and encouraging smoke-free environments. Of the 11 new awards, 10 are dedicated to obesity prevention, and one to tobacco cessation.
Seven of 10 deaths each year are caused by chronic diseases such as heart disease, cancer, stroke and diabetes. These same chronic diseases account for more than 75% of our nation’s healthcare spending, HHS says.
HHS also announced $10 million in additional funding for six communities ? all of which were part of the original 44 Communities Putting Prevention to Work communities - to provide mentoring to less-experienced communities based on their previous success in specific policy strategies. Funding for the “Community Mentoring” initiative comes from the stimulus package.
The awards are as follows:
$3 million to Alabama Department of Health: Mobile County, AL, for tobacco prevention
$2.3 million to Arkansas Department of Health: City of North Little Rock, AR, for obesity prevention; and Independence County, AR, for obesity prevention
$5.8 million to Children’s Memorial Hospital/City of Chicago, IL, for obesity prevention
$2.35 million to DeKalb County Board of Health, GA, for obesity prevention
$3.7 million to North Carolina Division of Public Health: Appalachian District Health Department, NC, for obesity prevention; and Pitt County, NC, for obesity prevention
$4.85 million to Pinellas County Health Department, FL, for obesity prevention
$3.6 million to Santa Clara County Public Health Department, CA, for obesity prevention
$3.8 million to Southern Nevada Health District, NV, for obesity prevention
$1.6 million to South Carolina Department of Health and Environmental Control for obesity prevention
The federal Pension Benefit Guaranty Corp. said this week it will assume responsibility for the pension plan covering more than 9,500 workers and retirees at the shuttered St. Vincent Catholic Medical Centers in New York City.
The SVCMC Retirement Plan is 55% funded, with assets of $345 million to cover benefit liabilities of $622 million, PBGC estimates. The agency expects to cover about $267 million of the $277 million shortfall.
PBGC said the intervention was necessary because the underfunded retirement plan will be unable to make benefit payments and will be abandoned after SVCMC's assets are liquidated, its activities cease, and there is no one left to administer the plan. By taking action now, PBGC prevents further deterioration of the plan's condition.
SVCMC, serving the Greenwich Village section on Manhattan's West Side, filed for bankruptcy on April 14, and by the end of May patients had been discharged or transferred to other hospitals, and debtors began selling off SVCMC's assets.
PBGC will take over the assets and use insurance funds to pay guaranteed benefits earned under the plan, which ended Sept. 14. Retirees and beneficiaries will continue to receive monthly benefit checks without interruption, and other workers will receive their pensions when they are eligible to retire. Until the PBGC becomes trustee, the plan remains ongoing under SVCMC sponsorship.
Under federal law, the maximum guaranteed pension at age 65 for participants in plans that terminate in 2010 is $54,000 per year, or lower for those who retire earlier or elect survivor benefits. Some early retirement subsidies and benefit increases made within the past five years may not be fully guaranteed.
PBGC will not have specific information about SVCMC pension benefits until it becomes trustee of the plan, when PBGC will send notification letters to all plan participants. SVCMC retirees who draw benefits from PBGC may be eligible for the federal Health Coverage Tax Credit.
SVCMC previously filed for bankruptcy in 2005 and emerged in 2007. As part of the plan of reorganization in that bankruptcy, PBGC negotiated an additional contribution of $75 million to the retirement plan and additional payments in later years.
PBGC is a federal corporation created under ERISA. It insures basic pension benefits of about 44 million American workers and retirees in more than 29,000 private-sector defined benefit pension plans. PBGC receives no general tax money. Operations are financed by insurance premiums paid by companies that sponsor pension plans and by PBGC's investment returns.
Supply chain management company MedAssets, Inc. Tuesday announced that it will pay $850 million in cash to acquire Dallas-based rival The Broadlane Group.
The Broadlane Group serves more than 1,100 acute care hospitals and 50,000 non-acute care facilities nationwide, and MedAssets serves more than 3,300 hospitals and 40,000 non-acute healthcare providers.
Using 2009 figures, the combined MedAssets and The Broadlane Group had estimated net revenue of $508.9 million and estimated combined adjusted EBITDA of $161.8 million, the two companies said in a joint statement.
"We are bringing together some of the best contract pricing in the industry, with highly complementary technology and clinical consulting expertise from both companies," said John Bardis, chairman/president/CEO of Atlanta-based MedAssets. "Our core strategy is to enable broader clinical and operating effectiveness throughout our nation's health system, and this transaction will further enhance our ability to help hospitals and other healthcare providers drive their operating and supply costs lower, while improving patient care."
Bardis said the collective strengths of the two companies will enhance MedAssets' financial profile, with recurring revenue, cash flow and profit expansion opportunities.
Patrick Ryan, chairman/CEO of The Broadlane Group, will join the MedAssets board of directors and become president of the company's Spend Management segment when the deal is finalized by the end of 2010.
"As a combined entity, we offer a strategic opportunity for our clients to drive operating expenses down while improving quality of care," Ryan said. "The collective strengths of The Broadlane Group and MedAssets will provide expanded supply chain capabilities, and further enhance the financial improvement opportunities, both near and long-term, for our healthcare provider clients."
The agreement calls for MedAssets to purchase The Broadlane Group for approximately $850 million in cash, with $725 million to be paid at closing and $125 million to be paid in January 2012. MedAssets has obtained financing from J.P. Morgan and Barclays Capital.
MedAssets said the combined company will offer:
An industry leader that can reduce hospital costs with supply chain management operations that include group purchasing, strategic sourcing, medical device or PPI cost management, centralized procurement, supply chain outsourcing, supply chain analytics and data services, lean process consulting expertise, and a clinical workforce or labor management solution;
A group purchasing portfolio that gives providers high compliance pricing and flexible contracting for commodity products and purchased services;
Software-as-a-Service-based revenue cycle technology and revenue cycle consulting and extended business office services that increase net revenue capture and cash flow improvement for healthcare providers with low upfront cost and a return on investment in months;
Approximately 85% recurring revenue with high client retention and minimal client concentration;
A national sales force and client service teams to expand use of the combined companies' services to new and existing clients;
Strategic support to help healthcare providers stay viable in the anticipation of healthcare reform and related financial/operational challenges.
Consumers remain confused and unsure of the timing for implementation of many provisions in the sweeping healthcare reform law that was passed by Congress last spring, according to a telephone survey from the National Association of Insurance Commissioners.
When asked to choose from four dates for which the first healthcare reform provisions officially take effect, only 14% correctly identified Sept. 23, 2010.
"Our survey findings are a clear indicator that most Americans are not aware of how soon some of the early healthcare changes may impact them," said NAIC President and West Virginia Insurance Commissioner Jane L. Cline. "It's essential for consumers to understand what to expect and when to consult their state insurance departments for more information."
When asked about specific reform provisions that take effect Sept. 23, 72% of respondents knew that children with pre-existing conditions may not be excluded from coverage and 70% understood that children up to age 26 may be covered under their parents' insurance.
However, half of the respondents incorrectly believed that employers with fewer than 50 employees will have to offer coverage to employees, and 47% incorrectly thought that all health insurance plans must cover approved preventive care and checkups without co-payment.
In reality, those qualifying for Medicare will receive new preventive care benefits that will include annual visits free of copayments, but this is not mandated for all health insurance plans.
"The results show that while most consumers are well attuned to provisions specifically affecting their children's healthcare, they do not grasp the overall reform framework," said Cline. "It's promising to see this, but we feel it necessary for consumers to fully understand the changes and get informed about what to expect."
NAIC conducted the Insurance IQ Omnibus national telephone survey of 1,000 adults on Aug. 12-15. NAIC said consumers with questions about the reforms should contact their state insurance department.
There are some interesting—but hardly surprising—findings in a report from the Medical Group Management Association and the Society of Hospital Medicine that show that base salary impacts both productivity and overall compensation for hospitalists.
According to the study, State of Hospital Medicine: 2010 Report Based on 2009 Data, hospitalists who receive a lower proportion of total compensation paid as base salary tend to be high producers who are incentivized to earn more.
The report—which contains information on 443 hospital medicine groups and 4,211 hospitalists—found that hospitalists who received 50% or less of their compensation as fixed base salary reported the highest median work relative value units (wRVUs) at 5,407. Hospitalists who received 51% to 70% of their compensation as base salary performed 4,591 wRVUs, compared to 3,859 wRVUs for hospitalists who received 71% to 90% of their compensation as base salary. Hospitalists who received 91% to 100% of their compensation as base salary reported 3,571 wRVUs.
In plain English, the report shows that the more a hospitalist receives in base pay as a percentage of overall compensation, the less incentivized he/she is to add to his/her workload. Of course! They have nothing to gain monetarily by improving productivity. If anything, they are disincentivized—as any employee would be—to do more work for the same money.
Though the study is new, the findings are hardly a revelation. Actually, the findings are a hard data affirmation that medicine is a business as much as it is a healing mission. The idea of paying more money for more and better work is bigger than hospitalists, and hospitals, and the entire healthcare system. It's human nature, and it's good old incentive-laced capitalism.
Hospitalists are among the fastest growing specialties, and a growing number of them are directly employed by hospitals. With that trend in mind, MGMA/SHM say more hospitals are catching on to this dynamic and moving away from straight base compensation and towards base salary and incentive packages that emphasize productivity and quality.
"This new data will prove tremendously helpful to hospitalists and healthcare executives alike," said William Landis, MD, chair of SHM's practice analysis committee. "While it is important to keep in mind that wRVUs cannot measure every work effort, this survey data will definitely support better decisions about how hospitalist practices are resourced, and it will ultimately promote delivering the best possible care to hospitalized patients across the country."
A further breakdown of the data showed that median wRVUs were higher for physicians in practices that were not hospital-owned than for physicians in hospital-owned practices. Physicians working in practices that provide on-call coverage at night generated more wRVUs than physicians working in practices that provide on-site care at night.
Internal medicine hospitalists reported median compensation of $215,000. Family practice hospitalists received $218,066 and pediatric hospitalists reported compensation of $160,038. Compensation varied based on geography, practice teaching status, and practice size.
Eagle Hospital Physicians, an Atlanta-based practice management company, has been acquired by private equity firms Highlander Partners, LP, and Flexpoint Ford, with equity fund Health Enterprise Partners, LP, the companies have announced in a joint statement.
Financial terms of the deal were not disclosed.
Eagle, which provides hospitalist contract services, telemedicine, and hospitalist temporary staffing to hospitals in the Southeast and Mid-Atlantic regions, named Brent McCarty as its chairman/CEO. McCarty was president/COO of revenue management specialists Alpharetta, GA-based Accuro Healthcare Solutions, Inc.
"Eagle has a great history of providing powerful hospital solutions by developing and managing hospitalist programs," McCarty said. "Moving forward, we're uniquely positioned to help our hospital partners meet their inpatient physician service needs. We will be making focused investments in people, process and technology, including improving and developing quality measurement systems and focusing on telemedicine and other specialty lines of business."
Robert Young, MD, founder/CEO of Eagle since 1998, will serve on Eagle's board. Mac McCormick, MD, senior medical director with Eagle since 2003, was named COO.
"Over the past decade, Eagle Hospital Physicians has gained recognition as one of the top hospitalist companies in the Southeast, providing inpatient solutions tailored to client hospital size, location and needs," Young said. "I am excited to partner with Brent McCarty as well as Highlander Partners and Flexpoint Ford to capitalize on the strategic opportunity to continue building Eagle."
Highlander Partners, based in Dallas, and Flexpoint Ford, with offices in Chicago and New York, specialize in private equity investments in middle-market companies in the healthcare and financial services industries. Health Enterprise Partners is a growth equity fund specializing in healthcare services and healthcare IT companies. HEP's investors include 16 of the nation's largest hospital systems and health plans.
Accessible, quality care for the elderly and disabled will become more difficult to find in the coming years under the new healthcare law because of draconian cuts in payments to doctors and hospitals, according to the National Center for Policy Analysis, a free market think tank.
Medicare payment rates will fall below the rates paid by Medicaid by the end of this decade and will fall even further behind all other payers in succeeding decades.
Medicaid pays about 80% of what private insurance pays today, but the payment rates will fall to two-thirds of private payment by the end of this decade and one-half of private payment by midcentury.
Just as Medicaid patients must often seek care at community health centers and safety net hospitals today, seniors could face similar access problems in the near future.
The financial breakdown:
The annual reduction in spending will reach $2,300 per beneficiary by 2020 and $3,844 per beneficiary by 2030.
By the time today's teenagers reach the retirement age, one-third of Medicare will effectively be gone.
If seniors are allowed to make up for the cuts in Medicare spending with out-of-pocket payments—something not allowed under current law—they will need to spend 10% of the average Social Security check by 2017.
In 2060 seniors will spend half of their Social Security income to offset the decline in Medicare spending.
Unless the law is changed, Medicare beneficiaries will be pushed into a separate healthcare system and not have the same access to care as the rest of the population, the report says.