Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
The White House has invited more than three dozen top lawmakers in the healthcare reform debate—20 Democrats and 17 Republicans from the House and Senate—to meet and discuss healthcare reform in a televised conference on Feb. 25. Some GOP members, though, are questioning the motives of the President.
In a Feb. 12 letter, signed by the President's Chief of Staff Rahm Emanuel and the Secretary of Health and Human Services, Kathleen Sebelius, they note that "when it comes to healthcare, the status quo is unsustainable and unacceptable." In particular, they cite the case of Anthem Blue Cross in which they said premiums would increase for many of its policyholders in California by as much as 39%.
If a comprehensive health insurance reform is not completed, this "enormous rate hike will be just a preview of coming attractions," they wrote. "Premiums will continue to rise" and "millions more will lose their coverage altogether or millions of our deficits will continue to grow large," they added.
"This is the closest our nation has been to resolving this issue in the nearly 100 years that it has been debated," they said. The President is expected to focus on four topics:
Insurance reforms
Cost containment
Expanding coverage
The impact that health reform legislation will have on deficit reduction
Several Republicans, though, have questioned the usefulness of having the summit, which is scheduled at Blair House, a block away from the White House.
Sen. John Kyl (R-AZ), the Senate minority whip, said Sunday on CNN's "State of the Union," he was "near certain" that congressional Democrats would try to use the budget reconciliation process—in which only a simple majority of 51 votes would be needed in the Senate—to move healthcare reform proposals through Congress.
"They have devised a process by which they can jam the bill through that the president has supported in the past without the Republican ideas in it," Kyl said. "Reconciliation is not the process for comprehensive bills like this. It's to balance the budget . . . I don't know why we would be having a bipartisan summit down at the White House if they've already decided on this other process."
House Republican Leader John Boehner (R OH) on Saturday said in a statement that "a productive bipartisan discussion" should begin with "a clean sheet of paper."
However, he challenged the impartiality of the summit, saying that "the president and his party intend to arrive with a new bill written behind closed doors exclusively by Democrats."
He added that the Democratic participants—which include chairmen of the five House and Senate committees that oversaw healthcare reform legislation last year—will engage in a "televised 'dialogue' according to a script they have largely pre determined," he said. "It doesn't sound much like bipartisanship to me."
The American Medical Association (AMA) got what it wanted Thursday when Senate Majority Leader Harry Reid (D-NV) removed a provision from the Senate jobs bill. The plan, which the AMA opposed, would have extended a Medicare payment cut for seven more months. Other healthcare provisions were removed as well.
"No one can dispute that we have a jobs bill," Reid said Thursday about the $80 billion pared-down bill. He added the "smaller package" he was introducing focused on highway programs, equipment write-offs, hiring tax credits, and building bonds.
Earlier in the week, the Senate inserted several provisions into the bill affecting physicians, hospitals, nursing homes, and other Medicare and Medicaid providers that expired on Jan. 1. With healthcare reform in the background, the jobs bill had appeared as a logical vehicle to move legislation ahead.
However, earlier in the week, the AMA criticized pushing off the proposed 21% Medicare payment cut as a "Band-Aid measure." The measure actually extended the current temporary fix—approved by Congress in late December—which expires at the end of February.
The AMA has been calling for a “permanent fix." The House approved a bill (HR 3961) in November that would have replaced the current payment formula. In October, the Senate failed to approve a similar measure. In recent weeks, AMA--joined by groups such as AARP and the Military Officers Association--have been calling for that change.
The healthcare provisions are expected to come back in separate "extenders bill" that the Senate could take up when it returns following the President's Day recess.
New changes are in the works for the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is sometimes referred to as the "psychiatrist's bible." The American Psychiatric Association (APA), which publishes the manual, placed a draft of the publication online this week and will seek comments on the draft through April 20.
"These draft criteria represent a decade of work by the APA in reviewing and revising DSM," said APA President Alan Schatzberg, MD, in a statement releasing the publication. "But it is important to note that DSM 5 is still very much a work in progress—and these proposed revisions are by no means final."
Members of 13 work groups, representing different categories of psychiatric diagnoses, have reviewed a wide body of scientific research in the field and proposed numerous revisions to the current DSM. They include:
Recommending new categories for learning disorders and a single diagnostic category—"autism spectrum disorders"—that will incorporate the current diagnoses of autistic disorder, Asperger's disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified).
Recommending that the diagnostic term "mental retardation" be changed to "intellectual disability," bringing the DSM criteria into alignment with terminology used by other disciplines.
Eliminating the current categories of substance abuse and dependence, and replacing them with the new category "addiction and related disorders."
Creating a new category of "behavioral addictions," in which gambling will be the sole disorder.
Adding new "suicide scales" for adults and adolescents to help clinicians identify those individuals most at risk, with a goal of improving interventions; the scales include research based criteria, such as impulsive behavior and heavy drinking in teens.
Adding a new diagnostic category, temper dysregulation with dysphoria (TDD), within the mood disorders section of the manual to assist clinicians when differentiating children with these symptoms from those with bipolar.
Recognizing binge eating disorders and including improved criteria for anorexia nervosa and bulimia nervosa, as well as recommended changes in the definitions of some eating disorders.
Following review of the public comments, the draft will be refined over the next two years. The APA will conduct three phases of field trials to test some of the proposed diagnostic criteria in real world clinical settings. The last edition of the DSM was published in 1994.
No doubt about it, the past year was a demanding one for healthcare providers and organizations. Not only did they have to grapple with a slow economy, they had to second guess what among all the shifting federal health proposals might survive. These issues appeared challenging to those individuals—including chief quality officers, chief nursing officers, and other healthcare executives—who are in charge of leading quality and patient safety efforts at their organizations.
In our HealthLeaders Media Industry Survey 2010 released this week, quality leaders again ranked the category "quality/patient safety" as their organization's No. 1 priority this year—just like in the previous year. This year, 65% selected this category, but it represented a 19-point drop from the last year's 84%.
While patient experience/patient satisfaction was a strong second place as a priority this year (54%), two cost-related categories moved into third and fourth places. "Cost reduction," in third place, was cited as a priority by 29%—up from 19% the previous year's. And "reimbursement" was in fourth place, sited by 23%—up from 13%.
To get perspective on the survey findings, I spoke this week with Rulon Stacey, PhD, president and CEO of the Poudre Valley Health System based in Fort Collins, CO. PVHS, a 2008 Malcolm Baldrige National Quality Award winner, includes two hospitals and a network of clinics and care facilities in Colorado, Nebraska, and Wyoming.
Economic problems brought on by the recession—and the impact on their healthcare organizations—appeared to be on the minds of those surveyed this year. Out of 151 quality leader respondents, more than three-fourths (76%) said it weakened their organization's financial position. Nearly 18% said it did not affect their organizations, while 6% said it improved their financial position. [See Question 11.]
Nearly a third (35%), though, thought their leadership was highly effective and another third (38%) thought their leadership was slightly effective regarding the recession and economic crisis. [Question 10.] Morale, however, has taken a hit, more than 81% saying morale had been weakened at their organizations because of the recession.[Question 12.]
"We've had tougher years. It wasn't our best year, but it wasn't our worst year either," Stacey says. The key became anticipating an economic downtown. "When people would call me last year and ask how are you addressing the recession, the financial challenges, my answer is we started for that 10 years ago."
"We started a process that allows us to get information to make changes—to be quick to address issues in the market using data- driven solutions," he says. "I feel like we were prepared for last year—before it got here. We had our costs under control when we took the inevitable hit in revenue and the inevitable increase in bad debts."
As for strategies that would prove effective in dealing with the economic crisis, nearly half (45%) thought it would be slightly effective to support physician alignment, while 18% said it would be very effective. Revenue cycle enhancements also got a nod with 49% calling them "slightly effective" and 16% saying very effective. [Question 13.]
One of the major challenges facing health systems today is "how are we going to integrate with physicians and health plans," Stacey says. "How are we going to create a truly integrated clinical structure that will allow us to share information, improve quality, and decrease costs as a collective—not just physicians working alone or hospitals working alone."
Tougher to anticipate was the potential impact of healthcare reform and new regulations on providing quality care at their organizations. For the next three years, nearly two-thirds (63%) of those responding expected that "ever-changing government regulations" to present a major challenge to their organizations; and a third (34%) thought it would be a moderate challenge. [Question 29.]
"I think another issue that we're facing is simply the uncertainty of where the health reform issue is going to go. An important part of leadership in healthcare is strategic planning, envisioning and preparing for the future," Stacey says. "The organizations that have been successful in the past have been those that have been able to determine where the industry is going—and then get ahead of that."
"But when the industry is so fluid, and the future is so uncertain based on so many political barriers, it's hard to predict the future—and it's hard to get ahead of the future. "It's hard to be an effective leader at a time like this," he says. The uncertainty tends to "drive mediocrity through everything—and that's not helpful either."
In terms of implementing best practices, more than half (53%) say that represents a moderate challenge, while 18% viewed it as a major challenge, and 24% as a minor challenge.
"Obtaining the information actually is hard," says Stacey. Organizations often spend a lot of time trying to find out how they can get the best outcomes. This means tapping into resources nationally—and even internationally. "It's just tough to find forums where the best organizations are explaining what it is that they do."
In the area of patient safety, getting hospital staff and physicians to comply with an organization's quality and safety goals was seen as a moderate challenge by nearly half (47%) of those responding; nearly a quarter (25%) viewed it as a major challenge.[Question 29.]
Stacey notes that when it comes to patient safety, it's important to have a process in place "where we can identify . . . and address those problems, because if we can't identify the areas where we have the greatest opportunity for improvement, then those areas continually become problems," he says.
"The process we have is where we measure everything: We know when an indicator falls out of an acceptable range and then we're able to respond quickly enough to address that so it doesn't become an issue down the road."
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Since President Obama's State of the Union address two weeks ago, interest in the Senate seems to be more focused on passing a jobs bill than the healthcare reform bill in the immediate future—but that doesn't mean healthcare is completely out of the picture.
Tucked into drafts of the jobs bill making their way around Capitol Hill are various healthcare provisions—many of which are temporary in nature and are directed at holding various programs in place until legislators can deal with the issues more completely through a healthcare reform measure.
They include:
Providing a seven month extension (until the end of fiscal 2010 on Sept. 30) of the Medicare payment fix that would postpone 21% physician Medicare payment cuts. (The current temporary fix approved by Congress in late December expires at the end of this month.)
Changing the definition of "hospital based physician" under the American Recovery and Reinvestment Act's HITECH provisions to allow physicians who practice in hospital owned outpatient centers and clinics to qualify for federal payment incentives for health information technology (HIT). The clarification to the ARRA language would be used to make sure that the Centers for Medicare and Medicaid Services does not exclude physicians providing services for patients in outpatient centers from receiving Medicare and Medicaid HIT incentive payments.
Making technical corrections to extend payments through 2010 for certain Medicare programs, such as Part B therapy caps, ambulance add on payments, and expanded payments for mental health services.
Making technical corrections to reimburse critical access hospitals at 101% of their reasonable costs for specified outpatient services, and to extend various Medicare payments to long-term care hospitals and rural hospitals through 2010.
Every year, healthcare providers dispose of millions of dollars of stored vaccines when those vaccines become too warm or too cold.
However, researchers at the National Institute of Standards and Technology (NIST) in Gaithersburg, MD—with funding assistance from the Centers for Disease Control and Prevention (CDC)—recently completed the first of a series of tests to find out the best practices for properly storing and monitoring refrigerated vaccines.
These initial findings will be included in a CDC training video and report scheduled for July. To ensure they are effective, most vaccines must be kept between 2 and 8 degrees Celsius—from the time they are manufactured until they are administered, the researchers said.
In the first study phase, NIST researchers compared standard sized refrigerators without freezers against smaller, dormitory style refrigerators. They used a variety of conditions, storage practices, and use scenarios—including leaving the refrigerator door ajar for various periods, power loss, and raising the ambient temperature of the room.
The NIST Thermometry group found that standard sized, freezerless refrigerators always performed better than the smaller, dormitory-type refrigerators by every measure. But, the study also identified several good practices for vaccine storage:
Vaccines should never be kept on the refrigerator door shelves because the lack of insulation in the door allowed unacceptable temperature drifts.
Vaccines also should be kept away from the walls of the refrigerator because the defrost cycle could cause the temperature of the walls to shift.
Vaccines should never be placed in crisper drawers, which are usually found at the bottom of standard refrigerators, because these areas are often shown to drop below 2 degrees Celsius.
Water bottles kept on the door shelves provided "thermal ballast," which helps slow temperature rises in the event of power failures, leaving the door ajar, or raising the temperature of the room where the refrigerator is kept.
According to a NIST study, vaccines that have not been removed from their packaging—usually a cardboard box—retain their temperatures longer than those that have been unpacked and placed in trays. The standard sized refrigerators' ability to keep proper temperature was unaffected by how much vaccine the researchers stored in the refrigerator—a characteristic usually not shared by the dormitory style refrigerators.
"While we don't advocate any particular brand of refrigerator, we can say that the standard sized freezerless refrigerators perform very well, but the dorm style refrigerators do not and should not be used for storing vaccines," said NIST physicist Gregory Strouse.
He added that the research showed that healthcare providers really do not need to spend "several thousand dollars on a pharmaceutical grade refrigerator simply for the purpose of storing vaccines."
The NIST group plans said it plans to perform further comparisons of standard sized refrigerators with freezers and pharmaceutical-grade refrigerators. It also will evaluate strategies for shipping vaccines overland.
A new three-pronged initiative to reduce unnecessary radiation exposure from three types of medical imaging procedures—computed tomography (CT), nuclear medicine studies, and fluoroscopy—was announced by the Food and Drug Administration (FDA) on Tuesday.
These combined procedures are considered the leading contributors to total radiation exposure in the U.S., because they use higher radiation doses than other radiographic procedures, such as standard X rays, dental X rays, and mammography, according to the FDA.
Of concern is exposing patients to ionizing radiation—a type of radiation that can increase an individual's lifetime cancer risk.
"The amount of radiation Americans are exposed to from medical imaging has dramatically increased over the past 20 years," said Jeffrey Shuren, MD, JD, director of FDA's Center for Devices and Radiological Health, in a statement. "The goal of FDA's initiative is to support the benefits associated with medical imaging while minimizing the risks."
As the first prong of the initiative, FDA said it intends to issue targeted requirements for manufacturers of CT and fluoroscopic devices. These requirements address safeguards in the design of their machines and provide appropriate training to support safe use by practitioners. FDA said it will hold a public meeting on March 30 31 to solicit input on what requirements to establish.
For the second part of the initiative, FDA and the Centers for Medicare and Medicaid Services will work together to incorporate key quality assurance practices into the mandatory accreditation and conditions of participation survey processes for imaging facilities and hospitals.
FDA is recommending that healthcare professional organizations continue to develop—in collaboration with the agency—diagnostic radiation reference levels for medical imaging procedures, and increase efforts to develop one or more national registries for radiation doses. A dose registry would pool data from many imaging facilities nationwide, and capture dose information from a variety of imaging studies.
For the third prong, FDA said it is working to empower patients and increase awareness by collaborating with other organizations to develop and disseminate a patient medical imaging history card. This tool, which will be made available on the FDA's Web site, will permit patients to track their own medical imaging history and share it with their physicians, especially when it may not be included in their medical records.
The FDA action follows an announcement made a week earlier by the National Institutes of Health (NIH) that its physicians will begin recording radiation doses for patients in their medical records, according to an announcement in the recent issue of the Journal of the American College of Radiology.
A radiation reporting policy has been developed at the NIH Clinical Center in Bethesda, MD, that will be used in cooperation with major equipment vendors--beginning with exposures from CT and PET/CT.
All vendors that sell imaging equipment to the clinical center will be required to "provide a routine means for radiation dose exposure to be recorded in the electronic medical record," said David A. Bluemke, MD, the study's lead author and director of Radiology and Imaging Sciences at the Clinical Center.
In addition, radiology at NIH also will require that vendors ensure radiation exposure can be tracked by patients in their own personal health records. This approach is consistent with the American College of Radiology's and Radiological Society of North America's stated recommendation that "patients should keep a record of their X ray history."
All lots of monovalent 2009 H1N1 influenza vaccine in pre-filled syringes manufactured by Sanofi Pasteur—and not included in two earlier recalls—have a shorter expiration period than indicated on the label, according to a new health alert from the Centers for Disease Control and Prevention (CDC).
To ensure that the vaccine meets potency standards, the vaccine—which had previous expiration dates ranging from March 2011 to June 2011—should be used by Feb. 15, the manufacturer said. These lots were shipped between November 2009 and January 2010.
No additional Sanofi Pasteur pre filled syringes will be available after Feb. 15; however, pre filled syringes from Novartis and CSL will remain available.
The 50 lots being recalled are those not included in two earlier recalls of other lots of H1N1 flu vaccine in pre-filled syringes from Sanofi Pasteur.
Individuals who received the vaccine from the lots with shortened shelf life do not need to take any additional action, the CDC said. All pre filled H1N1 Sanofi Pasteur flu syringes that have not been used by Feb. 15, should be discarded in an appropriate manner, or returned to the company for destruction, according to the CDC.
A total of 124 million doses of all brands of the H1N1 flu vaccine have been shipped around the country, said CDC respiratory disease chief Anne Schuchat, MD, at a news briefing on Friday. "It's really easy to be vaccinated now, and we hope people will take advantage of that."
Approximately 70 million people have been vaccinated against the H1N1 virus, Schuchat said, which translates to about 23.4% of Americans.
Schuchat said that H1N1 flu cases have been below the national baseline for the past three consecutive weeks. "That's fairly similar to what we would normally see at this time of year with seasonal flu," she said. However, pneumonia and influenza deaths as a proportion of total deaths have actually been above "the epidemic threshold level" for three consecutive weeks.
"Nearly all the flu viruses that we're seeing right now are the H1N1 pandemic strain. We're not seeing seasonal flu strains yet in any substantial numbers," she said. "We are remaining vigilant here and do not think people should become complacent. As I said, individual cases of the H1N1 influenza continue to occur, and people are being hospitalized. They're dying."
President Obama announced Sunday that he will meet with congressional Republicans and Democrats on Feb. 25 to discuss ways to move forward with healthcare reform this year.
Speaking with CBS anchor, Katie Couric, in a pre-Super Bowl interview, he said he wants to "put their ideas on the table" during a half-day meeting that will focus on the stalled healthcare legislation.
The goal will be to "go through, systematically, all the best ideas that are out there and move it forward," Obama said. The session is expected to be televised.
Prior to the interview, Obama reaffirmed that he was seeking to get some type of healthcare reform through this year. Speaking at a Democratic National Committee fundraising reception in Washington last week, he said, "We've got to move forward on a vote. But as I said at the State of the Union, I think we should be very deliberate, take our time."
The jobs package going through Congress is the "most urgent right now in the minds of Americans all across the country," Obama said. But the meeting will "allow everybody to get the real facts about the healthcare crisis that we face," and why it's so important for deficit reduction—and for families all across the country, he added.
"The key is to not let the moment slip away," Obama said. "I have to say part of what makes healthcare so hard—and why we are the only advanced nation on Earth that doesn't have some form of universal health care—is because even when the system doesn't work, people still want to kind of cling on to the devil they know because they're worried about the devil they don't," he said.
“If you go out there right now [and], you ask the average person . . . they're certain that they would have to go into a government plan, which isn't true," he said.
“But that's still a perception a lot of people have.
They're still pretty sure that they'd have to give up their doctor . . . They're still positive that this is going to add to the deficit," he said.
Upon release last month of a Gallup Survey of opinion leaders about nursing leadership, Risa Lavizzo Mourey, MD, president and CEO of the Robert Wood Johnson Foundation (RWJF), said the organization commissioned the survey because of the importance related to "expanding the leadership of nurses and tapping into all the wisdom and expertise that nurses have [which] is critical to healthcare reform and the healthcare system."
In the survey of 1,500 opinion leaders, nurses were viewed as one of the most trusted sources of health information, but they were often seen as having less impact on healthcare reform than government, insurance and pharmaceutical executives, and others.
Many nursing leaders, though, think the tide may be turning in that area and that the roles of nurses—and the work that they do—will be steadily influencing the movement toward healthcare reform and emerging health policy and research issues. Overall, they need to take advantage of opportunities that are opening up to them now.
Some of those opinions were expressed at the conference releasing the survey itself. "We do have considerable evidence about nurses' contributions" in areas such as patient safety, overall quality, care coordination, aging, and prevention, said Mary Naylor, PhD, RN, a professor at the University of Pennsylvania, School of Nursing, and program director of the RWJF Interdisciplinary Nursing Quality Research Initiative.
"We know nurses are making a major contribution in terms of improving value, quality, alignment with patients' experiences, and with family caregivers' experiences relative to investment in costs,” Naylor said. "Equally important, we are making major contributions—and we have major evidence to support this—in areas where opinion leaders have identified that we have little influence around access, around cost and efficiency."
"So the tremendous opportunity here is to get that message out as quickly as we can—to share the knowledge, to capitalize on every opportunity, to communicate what we know so that we continue to have others build on our ideas," she said. "We have a treasured gift here: The public trusts us. So we have to build on that foundation. We have to accelerate our ability to influence what it is that we know they need because [the public] is actually counting on us."
With healthcare reform being on the mind of many, "This is really an opportunity for all of us to begin to change our paradigm—the way that we think of healthcare being delivered," said Rich Hader, senior vice president and chief nursing officer at Meridian Health, an integrated healthcare system in New Jersey.
"When you think about it, nursing is at every avenue of the healthcare experience—whether or not it's in prevention and wellness, or diagnostic and treatment, or rehab or end-of-life care. It is the nurse who is the consistent, focused caregiver who is able to move us through that system," he said at the RWJF conference.
"What we need to make sure that we're able to do as nurses" is to be able translate what is "happening within our science" and be able to transmit that information into practice, said Hader. For many years, nursing, along with other medical professions, had been told in their academic programs that "this is how you do it . . . because it's been always done that way."
"We need to be able to continue to research more—to have better science that can actually dictate our practice that is based upon knowledge and information," Hader added.
In an interview, Diane Gurney, president of the Emergency Nurses Association, says, "I think we've come a long way from where we used to be, but we certainly can do better. We should have more influence, and I predict we will have more influence. I think we are in very exciting times."
She says she agrees with the Gallup Survey finding that while many nurses groups may speak out about issues, they don't have a "single voice" speaking on national issues. "We have a lot of 'one voices.' Everybody has their voice ... but we're in silos," she says. "We have to focus on those things that we can agree upon and maybe leave out the sacred cows—our own specialties— aside."
Carol Raphael, president and CEO of the Visiting Nurse Service of New York, said last month at a Brookings Institution forum on healthcare reform and older Americans, that new opportunities are emerging in which nurses can assume new roles. One example is the expansion of medical homes, which will place emphasis on the primary care team, which includes nurses.
Another model is transitional care—care after being released from a hospital. "I have to say I have seen a lot of heads of hospitals begin to pay enormous attention to the issue of readmissions. It is definitely on their radar screen," she said. "And while we all say transitions are vulnerable points, I think they're also an opportunity to begin to integrate, to build partnerships."
Her organization has trained its 2,500 nurses to use an algorithm—for those who are being discharged from a hospital—to predict patients' risks of rehospitalization. "If they come out high, we move in," she said. "And we now have begun some really strong partnerships with hospitals in targeting their population."
