Research suggests that these new disabilities can lead to readmissions, placement in a nursing home, and continued declines in patients' well-being.
Older hospital patients often encounter new disabilities after discharge, such as difficulty bathing, walking, and driving a car, a new study shows.
The research, published in the Journal of the American Geriatrics Society, suggests that these new disabilities can lead to hospital readmissions, placement in a nursing home, and continued declines in patients' well-being.
The study looked at data from the Precipitating Events Project of 515 people, with a mean age of 83, who lived at home at the beginning of the study, and who were hospitalized for acute, non-critical care.
The study participants initially were not disabled and did not need help with four basic activities: bathing, dressing, walking, and getting out of a chair. They were examined at home every 18 months and via telephone monthly.
From one-to-six months after discharge, one than one-third of participants reported various problems including: leaving home for medical care, getting dressed, bathing, walking across a room, getting in or out of a chair, walking a quarter-mile, climbing a flight of stairs, driving a car, doing basic housework, taking medications.
Some of the participants recovered from their disabilities one to two months after discharge, except for driving, which was less common.
In many cases, however, recovery was incomplete even six months after hospital discharge. For example, the proportion of people who were not disabled at six months was 65% for bathing and meal preparation, 58% for taking medications, and 55% for driving.
CMS administrator says her agency will "enhance" oversight of accrediting organizations "in the near future."
Centers for Medicare & Medicaid Services Administrator Seema Verma took a swipe at accrediting organizations on Tuesday, noting that when they accept consulting fees from the hospitals they grade it creates "a glaring conflict of interest."
Delivering the opening remarks at the 2020 CMS Quality Conference in Washington, D.C., Verma said her agency is "looking at ways to enhance our oversight of accrediting organizations."
"You're going to see more from us on this issue in the near future," she said.
Verma said that CMS in recent years has found inconsistencies in the way accrediting organizations inspect providers.
"Some even use standards that differ from our own, which is simply not acceptable," she said.
CMS in December 2018 put out a request for information from accrediting organizations that Verma says was designed to "ascertain the scope of the issue."
On Tuesday, Verma did not name specific accrediting organizations in her critique, but she called "a spate of serious deficiencies" that included patient harm and deaths at hospitals that had been deemed Medicare compliant "deeply concerning."
"Receiving CMS’s authorization to inspect and deem healthcare providers compliant with Medicare's quality standards is nothing short of assuming a sacred public trust responsibility," she said. "But an increasing amount of evidence indicates that accrediting organizations are not living up to that high bar."
"Our concerns are not only heightened by the growing trend of accrediting organizations providing fee-based consulting services to the same organizations they accredit; a glaring conflict of interest," Verma said, adding that CMS does not allow "these kinds of relationships" in other areas, such as Quality Improvement Organizations in Medicare or external reviews in Medicaid.
The Joint Commission, the nation's largest hospital accrediting organization, has denied any conflict of interest, citing a "long-standing firewall" it has created between its accrediting division and its consulting division, Joint Commission Resources, Inc.
"The Joint Commission recognizes the importance of assuring the integrity of the accreditation process, which we accomplish by prohibiting any sharing of information about consulting services for individual organizations with anyone involved in accreditation," the accrediting organization said.
Recommendations aim to reduce the effort and time required by clinicians to meet reporting requirements, record health information, and improve the functionality and intuitiveness of EHRs.
The federal government has released its long-awaited plan to reduce red tape and other administration snarls that create time-eating obstacles for doctors using health information technology.
"We received feedback from hundreds of organizations and healthcare providers on this new burden-reduction strategy, and the input made clear that there are plenty of steps still necessary to make IT more usable for providers and maximize the promise of electronic health records," HHS Secretary Alex Azar said in amedia release.
The final report, the end product of a draft, issued in November 2018, was led by the HHS Office of the National Coordinator for Health Information Technology and the Centers for Medicare & Medicaid Services, and includes input from the more than 200 comments.
"The taxpayers made a massive investment in EHRs with the expectation that it would solve the many issues that plagued paper-bound health records," CMS Administrator Seema Verma said.
"Unfortunately – as this report shows – in all too many cases, the cure has been worse than the disease," Verma said. "Twenty years into the 21st century, it's unacceptable that the application of Health IT still struggles to provide ready access to medical records – access that might mean the difference between life and death. The report's recommendations provide valuable guidance on how to minimize EHR burden as we seek to fulfill the promise of an interoperable health system."
About 52,000 physicians worked as locum tenens in 2019, representing about 6% of all practicing physicians.
About 85% of hospitals, medical groups, and other provider venues used locum tenens doctors in 2019, mostly to maintain services until permanent physicians could be found as replacements, according to anewsurvey from Staff Care.
"Virtually every hospital in the United States now uses locum tenens doctors," said Staff Care President Jeff Decker. "They have emerged as a key part of the medical workforce in an era of physician shortages and evolving delivery models."
Staff Care estimates that about 52,000 physicians worked as locum tenens in 2019, representing about 6% of all practicing physicians.
Decker said more physicians are choosing to become locum tenens "because it allows them to focus on what they like to do best, which is treat patients, while minimizing the administrative duties they like least."
The increasing use of locum tenens comes with the rise of the employed physician model, which gives physicians more freedom to switch jobs, Decker said, thus creating more temporary openings, and increasing the demand for locum tenens.
Employed physicians' vacation and continuing medical education time off each year also increases demand for locum tenens, Decker said.
The survey found that primary care physicians are the most in-demand locum tenens doctors, with 30% of healthcare facility managers reporting that they used locum tenens primary care doctors in 2019. However, the use of locum tenens primary care doctors in 2019 is down from 44% in 2016, Staff Care's last survey.
Conversely, the use of locum tenens specialists has grown. In 2019, 21% of healthcare facilities managers reported using locum tenens surgeons, up from 11% in 2016; 17% reported using locum tenens internal medicine subspecialists, up from 9%; and 22% reported using locum tenens anesthesiologists, up from 11%.
Demand also continues to be strong for locum tenens nurse practitioners and physician assistants, with 32% of healthcare facility managers reporting use of their services in 2019, up from 26.4% in 2016, and 9.5% in 2012.
Nearly two-thirds (62%) of health facility managers rated the skills of locum tenens physicians as excellent or good, while 33% rated the skills as adequate, and 4% rated the skills as poor.
Decker said the demand for specialists is being fueled by an aging general population and an aging physician workforce.
Last April, the Association of American Medical Colleges projected a shortage of up to 122,000 physicians by 2032, including up to 55,000 primary care doctors and up to 67,000 specialists.
"Older patients need specialists to care for ailing organs and body systems," Decker said. "We simply don’t have enough of them to go around."
Guardian directed its nursing facilities in Pennsylvania, West Virginia, and Ohio to upcharge Medicare at the highest level for medically unnecessary services.
Guardian Elder Care will pay $15.4 million to settle whistleblower allegations that its nursing facilities in three states knowingly overbilled Medicare for six years by providing unneeded rehabilitation services, the Department of Justice said.
"The department will not tolerate nursing home operators that put their own economic gain ahead of the needs of their residents, and will continue to hold accountable those operators who bill Medicare for unnecessary rehabilitation services," Assistant Attorney General Jody Hunt of the DOJ's Civil Division, said in a media release.
According to federal prosecutors, from 2011 through 2017 Brockway, PA-based Guardian directed its nursing facilities in Pennsylvania, West Virginia, and Ohio to upcharge Medicare at the highest level, even when the services were not medically necessary and were prompted more by financial considerations than residents' needs.
The allegations were originally brought by two former Guardian employees, who will split $2.8 million from the settlement.
The settlement also resolves allegations voluntarily disclosed by Guardian that it received inappropriate payments for ineligible services because the company had employed two people who were excluded from federal healthcare programs.
In prepared remarks, Patricia McGillan, Guardian Elder Care's Chief Compliance Officer, said the company is "committed to meeting our obligations under this agreement."
"We are confident that Guardian’s Corporate Compliance Program advocates for our patients, their families and caregivers," she said.
Hospitals recognized for high-quality cardiac care are more likely to be penalized under value-based programs than other hospitals.
No good work goes unpunished.
Hospitals that are recognized for high-quality cardiac care are also more likely to be penalized under value-based payment models, according to a new study inJAMA Cardiology.
Researchers at Beth Israel Deaconess Medical Center in Boston found that hospitals awarded by the American Heart Association and American College of Cardiology for their high-quality care for acute myocardial infarction and heart failure were more likely to be financially penalized under value-based programs than other hospitals.
"Our findings highlight that evaluations of hospital quality for acute myocardial infarction and heart failure care differ between AHA/ACC national quality improvement initiatives and federal value-based programs," said study lead author Rishi Wadhera, MD, an investigator at BIDMC's Smith Center for Outcomes Research.
"Hospitals recognized by the AHA/ACC for high quality care were more likely to be financially penalized by federal value-based programs than other hospitals, despite achieving similar and/or better outcomes," Wadhera said.
The findings show that federal incentives are not aligned with prevailing medical consensus on what constitutes appropriate cardiovascular care.
The Hospital Readmissions Reduction Program slaps financial penalties on hospitals with high 30-day readmission rates, while the Hospital Value-Based Purchasing Program rewards or penalizes hospitals based on their performance on multiple domains of care, including 30-day mortality.
Both programs have focused on heart failure and AMI because their clinical and financial burden.
The BIDMC researchers looked at some award-winning hospitals and found they were also more to be penalized by the HRRP and VBP compared with other hospitals. The award hospitals were also less likely to see reimbursement increases by the VBP and saw higher median payment reductions and lower payment increases under the VBP than other hospitals.
The researchers suggested that the award hospitals are being penalized by the value-based programs for factors unrelated to the quality of care. The award hospitals were larger, urban, teaching hospitals with a poorer, sicker, more complex patient mix.
That fragile patient mix not taken into consideration by risk-adjustment models used for value-based programs, which means that award hospitals could be getting penalized for the populations they serve rather than for the quality of the care delivered.
"As the shift to value-based care continues in the United States and as multiple bodies simultaneously assess hospital systems, we need to prioritize efforts to promote fair, equitable and standardized measurement of cardiovascular care quality," Wadhera said.
Study finds nonprofit hospitals with thicker bottom lines gave disproportionately lower levels of charity care.
The nation's top-earning nonprofit hospitals doled out less charity care than lower-earning hospitals did, relative to their respective profits, according to a new study from Johns Hopkins University.
In the research letter, published this week in JAMA Internal Medicine, Ge Bai, an associate professor at Johns Hopkins Carey Business School, examined 2017 Medicare cost reports from the Centers for Medicare and Medicaid Services for 2, 563 acute-care hospitals.
For every $100 of net income, hospitals in the top-earning quartile gave $11.5 of charity care to uninsured patients and $5.1 to insured patients.
Hospitals in the lower, third quartile of income gave considerably more – $72.3 to the uninsured and $40.9 to the insured.
"For both insured and uninsured patients, non-profit hospitals with superior financial performance provided disproportionately low levels of charity care," the researchers concluded.
"Nonprofit hospitals with substantial financial strength should consider more generous financial assistance eligibility criteria to reduce the financial risk exposure of disadvantaged uninsured and underinsured patients."
The top 1% of high-earning hospitals generated 23% of the net income of all nonprofit hospitals and provided 7% (to the uninsured) and 5% (insured) of the charity care at all nonprofit hospitals.
"The highest-earning hospitals have done very well financially," Bai said in comments accompanying the study. "The top 1% made more than $10 billion profit, and the top 5% more than $25 billion. Yes, they take certain measures to help financially disadvantaged patients, but they’re positioned to do more."
The 640 top-earning hospitals generated nearly $48 billion in net income in 2017 – or slightly over 100% of all net income reported by the 2,563 hospitals. The bottom three quartiles of hospitals reported negative net income.
Study co-author Gerard Anderson, of the Johns Hopkins Bloomberg School of Public Health, said the research letter breaks new ground by examining charity care across hospitals' financial state, and detailing distinctions between charity care for insured and uninsured patients.
"Congress and state legislatures need to take a careful look at the proper balance between the hospitals' profits and their level of charity care. Too many very profitable nonprofit hospitals are providing little charity care," Anderson said.
The study also found that hospitals in states that expanded Medicaid under the Affordable Care Act gave less charity care than hospitals in other states did – $12 versus $37.8 for uninsured patients, and $8.7 versus $11 for insured patients, measured against every $100 of net income.
"Nonprofit hospitals have full discretion in designing their financial assistance policy," Bai said.
"The top-earning hospitals, which have substantial financial strength, should design more generous eligibility criteria to help uninsured and underinsured patients. The hospitals' nonprofit status and tax exemptions require such action," she said.
The appellate court ruled that HHS Secretary Alex Azar's approval of a Section 1115 waiver for Arkansas was "arbitrary and capricious."
A key healthcare policy initiative of the Trump administration suffered a major setback on Friday when a federal appeals court slapped down the administration's efforts to allow Arkansas to impose work requirements on "able-bodied adult" Medicaid beneficiaries.
The three-judge panel at the U.S. Court of Appeals for the District of Columbia upheld a lower court when they ruled unanimously for the plaintiffs in Gresham v. Azar.
The appeals court said that the Department of Health and Human Services granted Arkansas' Section 1115 waiver for work requirements without considering its full effect on the Medicaid program and beneficiaries, a violation of the federal Administrative Procedure Act.
In a 19-page ruling, Judge David Sentelle, a Reagan appointee, called HHS Secretary Alex Azar's waiver approval process "arbitrary and capricious" and said HHS ignored concerns raised by stakeholders and beneficiaries about the potentially negative impact the waiver would have on coverage.
"In total, the Secretary's analysis of the substantial and important problem is to note the concerns of others and dismiss those concerns in a handful of conclusory sentences," Sentelle wrote. "Nodding to concerns raised by commenters only to dismiss them in a conclusory manner is not a hallmark of reasoned decision making."
It is not clear if the federal government intends to appeal the ruling, which could eventually be heard in the U.S. Supreme Court. Calls to the Centers for Medicare & Medicaid Services were not returned on Friday afternoon.
Stewart v. Azar consolidated suits from Arkansas and Kentucky that challenged waiver approvals for Medicaid beneficiaries. The court dismissed the Kentucky complaint after newly elected Democratic Gov. Andy Beshear ended the work requirement program in that state.
Jane Perkins, legal director of the National Health Law Program, a co-counsel for the plaintiffs, said she was "gratified" by the ruling.
"It means that thousands of low-income people in Arkansas will maintain their health insurance coverage — coverage that enables them to live, work, and participate as fully as they can in their communities," she said.
"Section 1115 of the Social Security Act only allows the Secretary to approve experimental projects that further the Medicaid Act's purpose," she said. "As Judge Sentelle's opinion repeatedly notes, the text of the Medicaid Act is clear as to this purpose – to provide health care coverage. The agency was bound by the purpose Congress selected and could not change it as it attempted to do. Only Congress can do that."
Allowing states to impose work requirements for "able-bodied adults" on Medicaid has been a key, but contentious, policy initiative by the Trump administration.
CMS Administrator Seema Vermahas repeatedly defended the "dignity and pride that is derived from work—for paying one's own way—and I believe it is the desire of nearly every American to achieve financial independence."
"Our default position must always be to help and encourage those who are able to lift themselves up and find their footing again," she said.
However, critics of the work requirements dismiss them largely as either a stunt or a back doorway to pare the Medicaid rolls.
The Centers on Budget and Policy Priorities has said the work requirements would kick many low-income adults off Medicaid "including people who are working or are unable to work due to mental illness, opioid or other substance use disorders, or serious chronic physical conditions, but who cannot overcome various bureaucratic hurdles to document that they either meet work requirements or qualify for an exemption from them."
Roth, who previously served in executive roles at Northwest Hospital & Medical Center in Seattle and Ochsner Health System in New Orleans before arriving at St. Luke's in 2007, spoke with HealthLeaders about the challenges and opportunities he foresees in his role as top executive.
The following is a lightly edited transcript of Roth's comments.
HealthLeaders: Why do you want to be a CEO?
Chris Roth: First of all, I am firmly rooted in this community. I've got family that goes way back relative to Idaho roots. My kids are here. I believe in the community and making a difference, and St. Luke's has a large footprint in southern Idaho where Boise is.
It is personal work, for sure. I believe in our mission and the course that we've been on for the past few years and the people that wake up every day to provide care. I want to make a difference in the community that I'm a part of and one in which I plan to be here, hopefully, until I retire.
The opportunity to influence the organization and make a difference in the community relative to healthcare, and dealing with some of the challenges we face, that's why I want to do it.
HL: You've been in senior leadership for a long time. How do you see your role changing as CEO?
Roth: I believe the CEO needs to serve as the chief culture officer. Culture is a team sport and leaders shape that. As a CEO, it's my responsibility to set the tone from the top. We are a caring organization, and that is the product that we deliver, so I look forward to doing that and setting the example.
Where I'll be spending my time will change. Any senior leader needs to have a balance of being both inwardly focused, but also externally focused. Community relationships are incredibly important. St. Luke's is an organization that can have an influence on public policy. I'll be spending more of my time shaping those aspects of regional healthcare and policy.
And, I'll be leading the strategy that our board has adopted and approved and driving the organization forward to achieve our vision.
The day-to-day work will change, but I'm fortunate that I have the experience and the background in the organization to know where our challenges are and where our opportunities lie. I'm going into this with eyes wide open, but it's going to be a change.
HL: Going into this first year, what do you anticipate being your areas of focus?
Roth: We have a very solid mission and a vision. As an organization, we are committed to improving outcomes, addressing affordability, improving access, and we aim to be and remain a national leader in quality and safety.
We have a solid plan and a strategy going forward. With that as background, I expect that in the next many months, I'm going to be engaged with our employees, our community, our physicians, our legislators, all individuals throughout southern Idaho, to listen and hear how we can become the best partners in the state as it relates to providing healthcare.
HL: How does your commitment to the community affect any movement toward social determinants of health?
Roth: We have two key foundations that help build our strategy. One speaks specifically to population health. We define population health in the way that St. Luke's improves the health of people in our communities by taking accountability for outcomes in the total cost of care. We're taking financial and clinical account accountability. In fact, we have about 36% of our total revenues at full risk right now.
Secondly, we know that most healthcare outcomes are determined outside of a hospital or clinic or a health system setting. They're determined socially. We need to play a part as a key leader in addressing social determinants, but we can't do it alone. We're committed to partnering with others to help achieve those needs.
HL: What does it say about St. Luke's that they hired a new CEO from within?
Roth: Our board in the process was looking for the right leader at the right time. And I mentioned before the solid strategy and the success we've had as an organization. Anytime an organization makes a decision to go within, what they're saying is, 'We're on a strong path. We've got a good culture. We're looking for a leader to continue the great work and take us to the next level.'
HL: What do you see as some of the biggest challenges and opportunities in the broader healthcare delivery universe in the months and years ahead?
Roth: Our biggest challenge is tackling the issue of access and affordability. When I talk about access, it's meeting people where they want to be met relative to healthcare, the right place, the right time, the right care, and to do so in a way that's affordable and transparent.
We've got a healthcare system that has a lot of work to do. We have incentives that are misaligned. We have payment models and fee schedules and chargemasters and hospitals and insurance companies and the federal government that are part of this big ball of twine that needs to be unwound in a meaningful way for consumers.
Our challenge is achieving better outcomes at a lower cost, and I haven't seen many organizations in healthcare able to achieve that, but that's our aim, and that's our No. 1 challenge ahead.
HL: What role model did Dr. Pate provide for you heading into this job?
Roth: As a CEO, I have never seen anybody that was more committed to the organizational vision and in such a consistent way. He led by example. He talked about it relentlessly.
Seeing him do that over and over again, internally, externally, showed me the importance of consistency as a leader—in particular, CEO. He took some arrows along the way. There were people that doubted the vision he was laying out for the organization, and I saw him with an unwavering commitment to that. That was a good example for me.
HL: At the end of your tenure as CEO, what do you hope your legacy will be?
Roth: Two things: One, I hope and I expect that we will have made a meaningful improvement as it relates to the delivery of healthcare in the region that we serve that's high quality, including strong safety, accessibility, and affordability, and that we can look back to say we've solved some of the greatest healthcare challenges in Idaho.
Second, would be a strong, positive, thriving culture of caring individuals that is functioning as a highly aligned team and has fun in the process.
15 Arkansas hospitals are the latest of hundreds of other hospitals across the country challenging opioid makers and distributors.
A handful of Arkansas hospitals, strapped by opioid-related care costs, are filing suit against the drug makers, distributors and retailers who peddle the addictive drug.
In a suit filed in Washington County Circuit Court, the 15 plaintiff hospitals allege negligence, fraud and civil conspiracy by the defendants, which include Purdue Pharma, Johnson & Johnson, Abbott Laboratories and more than 40 other companies and individuals involved in the manufacturing, distribution, and sales of prescription opioids.
"The manufacturers' deceptive marketing techniques and the active evasion of effective controls over the distribution of opioids by retailers and distributors have caused this ongoing crisis," said plaintiffs' attorney Thomas Thrash, of Thrash Law Firm P.A. in Little Rock.
"Other than the patients who have experienced devastating and often lethal consequences, hospitals were the most direct victims of this conspiracy," Thrash said. "Hospitals continue to provide desperately needed care, much of which is uncompensated, to effectively treat opioid-addicted patients and have saved countless lives."
The Arkansas hospitals are the latest of hundreds of other hospitals across the country that have filed suits against opioid makers and distributors.
Arkansas ranks eighth in the United States for its opioid use rate, according to the state officials.
Between 2000 and 2016, the drug overdose rate in the state rose from 5.4 per 100,000 people to 14 per 100,000. These increases came, the plaintiff hospitals allege, while the opioid makers, distributors and retailers "engineered a dramatic shift in how and when opioids were prescribed and used."
"They organized a complex scheme to overstate the benefits and trivialize the risk of long-term opioid use and minimized the risk of dependence among patients who used opioids to treat chronic pain," the suit alleges.
The plaintiff hospitals cited a study in the Journal of Managed Care Pharmacy that showed opioid-related hospitalizations costs eight times more than the cost of treating patients without opioid use disorders.
A 2012 study in the journal Health Affairs found that the average opioid-related hospital stay for cost about $28,000, with 20% of those stays were covered by private insurance. The same study found the cost of that stay rocketed to an average of $107,000 if there was an associated infection, with only 14% of such patients covered by insurance.
"For more than 20 years, virtually every hospital in the United States has provided and continues to provide some amount of totally uncompensated patient care as a direct result of the opioid crisis. This is not a sustainable trend," said plaintiffs' co-counsel Don Barrett.
"America's hospitals can lead us out of the man-made health care disaster created by the defendants, but hospitals must receive new resources to help address two decades of financial loss," he said.
