Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
While issues such as permanently fixing the sustainable growth rate (SGR) formula have disappointed physicians, it still would be in their best interest to support the many provisions of the Affordable Care Act as they work at the practice of medicine, several White House officials write in the latest issue of the Annals of Internal Medicine released Monday.
No one is "more disappointed" than President Obama "who has made it clear" in a statement that he is "committed to permanently reforming this Medicare formula in a way that balances fiscal responsibility with the responsibility we have to doctors and seniors," write the authors who include Nancy-Ann DeParle, director of the Office of Health Reform and counselor to the President, and Ezekiel Emanuel, MD, the special advisor on health policy with the Office of Management and Budget.
The uncertainty surrounding the SGR policy is "a distraction and potentially a barrier for some physicians to embrace the Affordable Care Act," but physicians should not let their frustration over it "distract them from the improvements that healthcare reform delivers to their patients and the profession," they said.
By removing barriers, the new healthcare reform act will provide physicians with the opportunity "to evolve the way that they deliver care," officials said. This will give them appropriate incentives to focus on coordinating care "so that patients get the prevention they need, and those with chronic conditions avoid complications."
"Delivering on the promise of reform will require the full engagement of physicians," they added. The Affordable Care Act and the American Recovery and Reinvestment Act, they predicted, will likely to affect the practice of medicine in a number of ways including:
Focusing care around "exceptional patient experience and shared clinical outcome goals."
Expanding the use of electronic health records with capacity for drug reconciliation, guidelines, alerts, and other decision supports.
Redesigning care to include a team of non-physician providers, such as nurse practitioners, physician assistants, care coordinators, and dietitians.
Establishing, with physician colleagues, patient care teams to take part in bundled payments and incentive programs, such as accountable care organizations and patient-centered medical homes.
Proactively managing preventive care—reaching out to patients to assure they get recommended tests and follow-up interventions.
Collaborating with hospitals to dramatically reduce readmissions and hospital-acquired infections.
Engaging in shared decision-making discussions regarding treatment goals and approaches.
Redesigning medical office processes to capture savings from administrative simplification.
Developing approaches to engage and monitor patients outside of the office (e.g., electronically, home visits, other team members).
Incorporating patient-centered outcomes research to tailor care appropriate for specific patient population.
These healthcare reforms will "unleash forces that favor integration" across the continuum of care, they said. Plus, some organizing function will need to be developed "to track quality measures, account for and manage shared financial incentives, and oversee care coordination."
Consequently, the healthcare system will evolve into one of two forms: organized around hospitals or organized around physician groups, they predicted. These coordinating functions, to the extent that they currently exist, traditionally have been managed by hospitals or health plans.
Only hospitals or health plans can afford to make the necessary investments in information technology and management skills, they said. "This is not inevitable. As physicians organize themselves into increasingly larger groups—patient-centered medical home practices and accountable care organizations—they are, out of necessity, investing in information technology [IT] tools," they said.
These IT tools are "becoming both cheaper and more capable.” In addition, investing in the “acquisition or development of management skills” could provide these organizing functions efficiently for physicians groups, they added.
Physicians who embrace these changes and opportunities "are likely to deliver the greatest benefits to their patients, the health system, and themselves," they write. "For physicians, this means a profession that is more rewarding, more productive, and better able to realize its moral ideal."
Consumers have been economizing on healthcare costs in ways that could be dangerous to their health, including cutting back on their medications, according to a Consumer Reports National Research Center health prescription drug poll released Tuesday.
In the past year, 39% of more than 1,100 individuals interviewed said that they took some action save money. Among those surveyed, 27% who take medication said they failed to comply with their prescriptions, while 38% of those younger than 65 without drug coverage skipped filling prescriptions altogether.
The poll found that nearly half (45%) of Americans take at least one prescription drug on a regular basis, and on average, they routinely take four medications.
More than two-thirds (69%) of those taking prescription drugs said pharmaceutical manufacturers have too much influence on physicians' prescribing decisions, and half said that physicians are too eager to prescribe a drug when various non-drug options are available for managing a condition.
Another 51% said they thought that physicians did not consider a patient's ability to pay when prescribing a drug, nearly half (47%) said they thought gifts from pharmaceutical companies influenced physicians' choices of drugs for their patients, and 41% said they thought physicians tended to prescribe newer, more expensive drugs.
The advertising budgets of pharmaceutical companies are having an impact on consumers, the survey noted: 20% of consumers who take a prescription drug have asked their physicians for a drug they saw advertised, with a majority of those physicians (59%) agreeing to prescribe the medication.
The health poll also revealed that the public has a strong desire for more safety information and details about possible side effects: 87% said that knowing the safety of a prescription drug was a top priority to them, while 79% were concerned about drug interactions, and 78% cared about the side effects of a drug.
"The safety information provided on all fronts—in hospitals, at the doctor's office, and the pharmacy—is hit or miss," said John Santa, MD, MPH, director of the Consumer Reports Health Ratings Center in Yonkers, NY.
"When considering a new medication, consumers should ask their doctors about the drug in question, its purported use, how it should be taken, whether certain activities should be avoided, whether drug interactions are possible, and the types of side effects that could occur," Santa added.
According to the health poll, more than half (53%) of consumers currently taking medications have talked to their physicians in the past 12 months about switching to a different prescription drug, with side effects being one of the main reasons, in addition to cost and lack of insurance coverage.
While American Nurses Credentialing Center Magnet Recognition Program® (MRP) hospitals have been cited for promoting better patient safety and outcomes, they may not necessarily be providing better working conditions for nurses. Particularly in the area of scheduling and job demands, non-MRP hospitals are comparable to MRP-designated hospitals, according to researchers from the University of Maryland School of Nursing.
Nearly 350 healthcare organizations in the U.S. are currently recognized by the ANCC. Over the years, studies have identified attributes of MRP hospitals that attract nurses: high autonomy, decentralized organizational structure, and supportive management.
But MRP hospitals usually focus on the organization rather than the individual nurse, suggesting that personal demands may remain high among nurses providing frontline care at MRP facilities, they said in their study appearing in the July/August issue of the Journal of Nursing Administration.
"[MRP] Hospital tenets do address schedules, although the focus has been on other important issues" such as nurse autonomy and shared governance, says one of the researchers, Alison Trinkoff, ScD, RN, a professor with the School of Nursing. "It may get overlooked."
To examine the issue, a data analysis was conducted using the Nurses Worklife and Health Study with responses from the 837 nurses working in 171 hospitals (14 MRP and 157 non-MRP facilities).
Nurses in the MRP hospitals were found to be less likely to report jobs that included mandatory overtime or on-call, but the hours worked did not actually differ. While these nurses reported significantly lower physical demands, the mean measures for MRP hospital nurses and non-MRP nurses were similar, they said.
What appeared to be a common factor among nurses in MRP and non-MRP facilities were long hours and extensive use of overtime, Trinkoff says.
However, it doesn't need to remain this way: "Because [the program] was originally founded to help retain nurses, it could be an opportunity to think about ways of bringing people back into the workforce," Trinkoff says. "Many people have left because of the schedules....[but] I think there are opportunities to bring people back in?if we're a little more creative or offering choices of the work hours."
It may mean looking for a type of schedule that "brings in a whole new demographic of persons back," Trinkoff says. This could mean trying out more flexible hours and ensuring nurses at least get a break during the day by bringing in a nurse, for instance, from 10 am to 2 pm to relieve them.
"Who wants to work 10 to 2? Well, as it works out, sometimes folks who are older and don't want to work a long sustained day or folks with school-aged children who want to be there in morning or there when they return home,"she says.
Another aspect is getting commitments from hospitals that nurses can get out on time?that they work the hours they are truly scheduled to work," Trinkoff says. "It's already demanding, and adding to that the anxiety of whether ?I'll be able to leave on time? adds to it. It's a concern," she adds.
"It seems like a good thing for everyone?both for retention, satisfaction, performance, and quality?to look at the rest nurses are able to get. Are they able to be away from work and get time to recuperate?and come back fresh," she says. Overall, this is not just a MRP hospital issue but just a hospital issue.
"We know that [the program] has this issue [scheduling] as part of the focus and we just wanted to assess where things are," she says. "Hopefully, all hospitals will move forward. To me, the results suggest this is something that all hospitals could look at."
Enrollees in a health reimbursement arrangement—a consumer-directed health plan that combines a high-deductible health plan with a tax advantaged account—were found in both public and private plans to spend less on healthcare annually than those enrolled in other types of health plans, according to the Government Accountability Office.
One of the reasons may be that enrollees in HRAs tended to be healthier—and therefore kept costs down, according to a GAO report. This pattern was evident even before enrollees signed up for the HRA, GAO says.
For instance, the average annual spending per enrollee for the public employer's HRA group was $1,505 lower than a preferred provider organization (PPO) group for the two-year period prior to switching. Likewise, the private employer's HRA group spent $566 less per enrollee for the two-year period prior to switching to the PPO group.
At the same time, in 21 GAO-reviewed studies, 18 studies found they were healthier than traditional plan enrollees—based on utilization of healthcare services, self-reported health status, or the prevalence of certain diseases or disease indicators.
Overall, spending for private employer enrollees in HRAs generally increased by a smaller amount or just decreased compared with those in traditional plans that GAO reviewed.
With public employer, from the two-year period before switching (2001 to 2002) to the five-year period after switching (2003 to 2007), average annual spending for the HRA group increased by $478 per enrollee. At the same time, it increased by $879 for the PPO group.
This smaller increase for the HRA group was partially driven by decreases in spending for prescription drugs. Also, average annual use of services per enrollee increased by a smaller amount—or decreased—for the HRA group compared with the PPO group for six out of eight services GAO reviewed.
For the private employer, from the two-year period before switching (from 2001 to 2002) to the three year period after switching (2003-2005), average annual spending for the HRA group increased by $152 per enrollee compared with $206 for the PPO group.
This smaller increase for the HRA group was partially driven by smaller increases in spending for physician office visits and decreases in spending for emergency room services. Additionally, average annual use of services for each enrollee increased by a smaller amount—or even decreased—for the HRA group compared with the PPO group for four out of seven services GAO reviewed.
GAO also found in its analysis that:
While data from the national insurance carriers showed that enrollees in the HRAs were younger than those in PPOs, GAO's review of published studies produced mixed evidence on the ages of HRA relative to traditional plan enrollees.
HRA enrollees were more likely to elect single coverage than traditional plan enrollees, GAO found. However, data from the national insurance carriers showed that 44% of HRA enrollees compared with 42% of PPO enrollees opted for single coverage in 2004.
The published studies GAO reviewed "consistently found" that HRA enrollees had higher salaries than did traditional plan enrollees: for example, a case study of a large employer found the average salary of HRA enrollees was $93,409, compared with $69,555 for PPO enrollees.
Trauma center treatment cost more when compared with non-trauma centers, but the overall benefits in terms of lives saved and quality of life-years gained, represents a more cost-effective way of treating patients with major trauma.
The Johns Hopkins Bloomberg School of Public Health study found that the added cost of treatment at a trauma center versus a non-trauma center is $36,319 for every life-year gained or $790,931 per life saved. This is despite the fact that initial care in trauma centers is 71% higher than in non-trauma centers, say the researchers in The Journal of Trauma Injury, Infection and Critical Care.
Sources for the study include:
Data from 5,043 major trauma patients enrolled in the National Study on Costs and Outcomes of Trauma, a prospective study of severely injured adult patients cared for in 69 hospitals (18 trauma centers and 51 non-trauma centers) in 14 states
Claims data from CMS
UB92 hospital bills
Patient interviews
In addition to care received in the hospital, costs linked with:
Hospital transport,
Treatment at transferring hospital,
Rehospitalizations for acute care,
Inpatient rehabilitation,
Stays in long-term facilities,
Outpatient care,
Informal care from friends or family members
Lifetime costs were modeled using age-specific estimates of per capita personal health expenditures for the general U.S. population, along limited data on the impact of certain injures on lifetime healthcare costs.
While the value of a year of life is the subject of considerable debate, the researchers say that the costs per life-year saved at a trauma center are "well within an acceptable range of other cost-effective, life-saving interventions reported in the literature."
Cost-effectiveness was estimated as the ratio of the difference in costs, treatment at a trauma center vs. non-trauma center, divided by the difference in life years gained, plus lives saved, the researchers say.
Also, while trauma center care was cost-effective for all patients, it was particularly valuable for individuals with severe injuries and for patients younger than 55 years. The costs per life-year gained were higher for patients with less severe injuries.
"Each year in the United States, more than two million people are hospitalized for treatment of a traumatic injury. Because injuries often happen in children and young adults, the years of potential life lost are significant," says Richard Hunt, MD, director of the Division of Injury Response in the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention.
"We know that getting the most critically injured patients the right care, at the right place, at the right time can help save lives," he says.
Overall, the results underscore the importance of designing trauma systems that assures that patients are taken to the level of care appropriate to their needs, the researchers concluded. Taking the less severely injured to a lower level of trauma care will yield "lower costs and increased efficiency in the system."
The Department of Health and Human Services on Thursday released a report reviewing how to improve the federal government's system to produce and utilize medications, vaccines, equipment, and supplies in case of a public health emergency.
HHS Secretary Kathleen Sebelius had requested the review when the department encountered challenges with the 2009 H1N1 pandemic flu vaccine—highlighting the need for a modernized countermeasure production process. In particular, the review identified a need to upgrade the science and regulatory abilities at the Food and Drug Administration.
"Our nation must have a system that is nimble and flexible enough to produce medical countermeasures quickly in the face of any attack or threat, whether it?s a threat we know about today or a new one," Sebelius said in a statement.
The review also found that the United States must more quickly develop manufacturing processes that can be used for multiple medications or vaccines—rather than processes that produce only one type of countermeasure.
As a result of this finding, HHS is expected to shortly release a draft soliciting new "centers of innovation for advanced development and manufacturing" that can quickly produce a variety of countermeasures—without relying on foreign manufacturing.
The review also revealed that the federal government must do a better job nurturing discoveries in their earliest stages and subsequently letting them grow. To meet this need, HHS will be creating new teams at the National Institutes of Health to identify promising research and facilitate for ranslation into vaccines, drugs, and treatments.
Also on Thursday, NIH also announced its plans to invest $105 million over the next five years to develop products to diagnose, prevent, and treat the consequences of exposure to a radiological or nuclear attack. The National Institute of Allergy and Infectious Diseases? Centers for Countermeasures Against Radiation (CMCR) program, first established in 2005, will support research at seven institutions nationwide.
The National Association of Insurance Commissioners' Executive Committee unanimously approved the "blanks" template this week at its annual meeting in Seattle. The template, now available online, provides insight into what can be considered a medical expense under the minimum medical-loss ratio requirements.
The blanks, which are the forms submitted by insurers to state regulators when reporting financial information, will be used by the states in reviewing data and calculating medical-loss ratios. Under the new healthcare reform law, insurers with large group coverage plans are required to spend at least 85% of premiums on medical costs, and at least 80% of premiums for those plans with individual and small group plans starting in 2011. If any of the insurers fall short, they will be required to give customers a rebate for the difference starting in 2012.
The instructions, though, still might change depending on the definition of medical-loss ratio that the NAIC eventually approves this fall and forwards to the Department of Health and Human Services. HHS is responsible for certifying that language.
One major question slowing the deliberation is what is considered quality-related care—with consideration to such areas as nurses' hotlines, disease management programs, or public health education initiatives—and if and how that should be considered medical care under the ratio formula.
It already has caused concern in Congress. Earlier this month, more than four dozen senators and congressmen signed a letter sent to NAIC that asked it to "consider the strictest definition of 'quality improvement expenses' when implementing the mandatory medical-loss ratio standards."
However, America's Health Insurance Plans President and CEO Karen Ignagni said in her letter to NAIC after the vote on the template that "the current proposal could have the unintended consequence of turning-back-the-clock on efforts to improve patient safety, enhance the quality of care, and fight fraud."
In its statement, DMAA: The Care Continuum Alliance, a Washington-based trade group representing wellness and disease management program vendors, said the template "has strongly made the case that such services should be recognized as medical or quality improvement expenses in the medical-loss ratio."
HHS Secretary Kathleen Sebelius, writing in her blog earlier this week, said HHS has recently heard reports that some issuers were making decisions about participation in particular markets—based on the effect of these requirements.
"As we move forward, I urge insurance companies, consumer groups and other stakeholders to continue to participate in the process," she said. "It is premature for insurers to make business decisions about participation in particular markets based on rules that have yet to be published, or to apply for exemptions to rules that have not yet been drafted."
In a study released this month by the Agency for Healthcare Research and Quality, a startling finding was reported: one in five hospitalizations involved patients with diabetes. As one way to tackle this ongoing epidemic, a new pilot was unveiled last week in Chicago that calls for adult diabetic patients to receive a different kind of prescription from their physicians—one for fresh, healthy foods sold through a local well-known retailer.
Several weeks ago, I wrote about the importance of communities—and addressing such difficulties as finding nutritious, wholesome foods for purchase within many communities—in regard to individual healthcare. While medical care was said to prevent only 10% to 15% of premature deaths, social and cultural factors and the quality of environment were found to play a critical role in determining our overall health.
Keeping in mind that an important, but easy, way to control diabetes is through healthy diet and exercise, three groups— Northwestern Medicine (which includes Northwestern Memorial Healthcare), Walgreens Corp., and Near North Health Service (a federally qualified health center with eight clinical locations in the Chicago area)—launched a new program called "Greenlight Select."
This new pilot will be focusing on the diabetic patients of one of Near North's clinics—who live in an area where grocery stores are not convenient: where it's easier to buy potato chips than a bag of potatoes. When they visit their physician, in addition to medical prescriptions for their diabetes, they also will receive a prescription that lists "foods for a balanced diet" such as a variety of fruits and vegetables, meats and proteins, dairy, and grains.
These prescriptions will be redeemable for discounts initially at a Walgreens found in a "food desert" location in the health center's neighborhood. Walgreens will be supplying a section of its store with these foods. The retailer, though, has also been s redesigning 10 of its stores on Chicago's South and West Sides, as well, to include an expanded variety of fresh foods and healthy meal components.
The pilot is an expansion of the Diabetes Collaborative—Northwestern's and Near North's 5-year old program that has been teaching diabetic patients how to control their condition through healthy lifestyles. As one part of that initiative, Northwestern Medicine researchers developed educational modules and worked with Near North to construct two, full-scale mock grocery stores at two of its community clinics.
"In the past, we used to help [Near North] by just writing a check. But now what we do besides that is sit down together and brainstorm about health issues—some of their most pressing health issues... and [see] what we can do to expedite care and in that manner [achieve] better care," says Daniel Derman, MD, who is president of the Northwestern Memorial Physicians Group and vice president of community services for Northwestern Medicine.
In addition, researchers from Northwestern will be reviewing those patients who will or won't take advantage of the prescription program and see if this intervention in diabetes control makes a difference, he says. "This is one of the most exciting things in community service work that we're doing."
"Oftentimes, people think they know what the good things are to eat, but they don't always. And even if they do know, it's amazing that the power of a prescription [will have]," says Carolyn Lopez, MD, the medical director of the Near North Service Corp.
She recalls that many years ago, she wrote patients a prescription for exercise. "That power of a prescription really sent a strong message to patients about what their job is. It's just as important as anything else."
Likewise, having a nutrition prescription not only is able to show people what they need to eat, but gives them addition tips and information. "I think it's a really neat part of all of this," she says.
To solve the problem of being in the food desert, you "first need to create the oasis, but the oasis has to be more than a mirage," she notes. This means having a handy source for patients to obtain the foods—and then making those products affordable—essentially competitive with the cheaper but high-calorie or fattier foods.
She doesn't rule out expanding the prescriptions in the near future to other conditions that would benefit from healthy eating—for instance, heart problems, hypertension, or kidney problems. "To start out, we thought we'd go with that population that really has a profound need so we're starting out with the adult diabetics," she says.
Eating healthy, though, could mean other changes—especially for the family of the diabetic patient. "The reality is that what happens to families tends not to be isolated with one individual," she notes.
"People probably wouldn't want to cook three different meals for those with families—so you can begin shaping and reshaping how people shop, as well as how people prepare foods," she says. "You have a positive impact not only on the individuals who have the need—because of a health problem—but even for those who are not currently struggling with that kind of a problem."
In other words, eating healthy could become a way of life.
Based on bids that were submitted by plan sponsors, the average 2011 Medicare prescription drug plan (Part D) premiums will have nearly the same rates that beneficiaries are paying this year, the Center for Medicare & Medicaid Services announced Wednesday.
"The 2011 premiums on average will increase $1—from about $29 [this year] to $30 for the beneficiaries," said CMS Administrator Don Berwick, MD, in a telebriefing. "The benefits are going to be steady. Over 99% of participants are going to find in their local areas the opportunity to get into a 2011 plan with a premium that's the same or lower than the one they have now."
Since most premiums are going to remain stable, beneficiaries should keep in mind that they can shop and compare for the best premiums in their local areas, Berwick said. The modest increases in premiums, along with new discounts for brand-name drugs made through the Affordable Care Act, "are going to add stability" to the program, he added.
Berwick noted that under the original Part D statute, many low-income beneficiaries found themselves having to change plans if their current plan raised the premiums above the benchmark. The Affordable Care Act helps reduce the amount of the "disruption" for that population, he said.
Prior to the law, as many as 2.1 million low-income beneficiaries would have been required to change plans because of Part D premium changes, but now that rate is closer to 500,000 beneficiaries, he said. "That's the lowest number of beneficiaries who have been reassigned in the history of the Part D program."
The premiums paid by Part D enrollees cover about 25% of the cost of basic Part D coverage, according to CMS. Enrollees who have limited incomes can qualify for a low-income subsidy that typically would cover some or all of the beneficiary's premium, deductible, copayments, and the cost of drugs in the coverage gap.
Currently, more than 10 million beneficiaries are receiving this low-income subsidy. In 2011, the average value of the subsidy amount—when applied to the Part D benefit, premium, and cost-sharing for those enrollees—is estimated to be about $4,000.
In addition to national average premiums for 2011, CMS also announced the 2011 national average monthly bid, the base beneficiary premium, the regional low-income subsidy premium amounts for 2011, and the 2011 Medicare Advantage regional preferred provider organization benchmarks. The national and regional rate information is available at the CMS website. General information about plan offerings will be released in September.
While hospitals in the U.S. were found to vary in their policies and practices of surveillance, decolonization, and treatment of methicillin-resistant Staphylococcus aureus infections, most were found to be consistent with national guideline recommendations, according to researchers at the University of Illinois at Chicago.
The researches used a 61-item questionnaire sent to the directors of pharmacy at 263 acute care hospitals that were members of a national group purchasing organization. Responses were received from 102 hospitals (38.8%). Active surveillance culture protocols were found to be in place at 44 of those hospitals (44%), and MRSA decolonization policies were found in approximately 25% of the respondent hospitals.
Vancomycin was reported as the most commonly used antimicrobial in those hospitals for the treatment of various MRSA infections, followed by linezolid. Vancomycin was on the formulary in all hospitals with few restriction policies, while the newer anti-MRSA agents—linezolid, daptomycin, and tigecyclin—were on the formulary in most hospitals, but with restrictions.
About 70% of the responding hospitals reported having a vancomycin-specific dosing or monitoring guidelines in place. The use of actual body weight was specified for dosing and therapeutic monitoring of serum concentrations at 84% and 91% of the hospitals respectively.
Nearly 75% of the responding hospitals said they engaged in key antimicrobial stewardship activities, while just 18% reported having a formal antimicrobial stewardship team, according to the study, which appears in the American Journal of Health-System Pharmacy.
Nearly all of the hospitals surveyed said they had adopted hand-hygiene practices. Other preventive practices include the use of gowns and gloves and isolation of MRSA-positive patients, said Yoojung Yang, a fellow in the Center for Pharmacoeconomic Research who led the study.
"The results of our survey suggest that pharmacists play a key role in the treatment of MRSA infections," Yang says. Nearly 75% of the responding hospitals said they reviewed antimicrobial prescription orders and placed restrictions on the use of select antimicrobials in an effort to ensure optimal use of the drugs and to reduce the risk of bacterial resistance.