Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
Researchers at Rensselaer Polytechnic Institute in Troy, NY, this week announced that they have created a "nanoscale coating" for surgical equipment, hospital walls, and other surfaces that they say can kill MRSA. In tests, 100% of MRSA in a solution were killed within 20 minutes of contact with a surface painted with latex paint that was laced with the coating, the researchers reported.
"We're building on nature," says one of the researchers, Jonathan Dordick, PhD, director of Rensselaer's Center for Biotechnology & Interdisciplinary Studies. "Here we have a system where the surface contains an enzyme that is safe to handle, doesn't appear to lead to resistance, doesn't leach into the environment, and doesn't clog up with cell debris."
The research, led by Dordick and Ravi Kane, PhD, a professor in the Department of Chemical and Biological Engineering at Rensselaer, was published in the July issue of the journal ACS Nano, published by the American Chemical Society.
This technology could be marketed soon, Dordick says. With "appropriate translational work from the university to a company," non-health care applications would be commercialized first—possibly within a year. Then, healthcare applications would follow once regulatory approval was achieved—roughly a three-year process, according to Dordick.
Unlike other types of antimicrobial coatings, the paint is toxic only to MRSA and does not rely on antibiotics, he said. It also can be washed repeatedly without losing effectiveness, while maintaining a dry storage shelf life of up to six months. He added that he anticipated other infectious agents in the future could be decontaminated using this method as well.
Dordick said that this technology has advantages over the use of nanoscale silver, which also has antibacterial properties and is used in products such as washing machines and refrigerators. While nanoscale silver has been debated over concerns to human health and the environment, Dordick said their approach may be safer because the active agent is an enzyme, which does not have any activity against human cells, and the technology does not leach out from the paint or coating.
In their research, they said they were looking for examples in nature where enzymes could be "exploited" to counteract bacteria. They focused on lysostaphin—an enzyme secreted by non-pathogenic Staph strains—which is harmless to humans and other organisms but capable of killing Staph bacteria.
"Lysostaphin is exceptionally selective," Dordick says. "It doesn't work against other bacteria, and it is not toxic to human cells."
"The more the lysostaphin is able to move around, the more it is able to function," Dordick says. The material was successfully tested at Albany Medical College, where another researcher maintained strains of MRSA.
"At the end of the day we have a very selective agent that can be used in a wide range of environments—paints, coating, medical instruments, door knobs, surgical masks—and it's active and stable," Kane says. "It's ready to use when you're ready to use it."
The American Hospital Association has urged the U.S. Supreme Court in Mayo Foundation for Medical Education v. U.S., to reverse an Internal Revenue rule addressing whether medical residents qualify as students for purposes of receiving exemptions from Social Security taxes. The court agreed to hear the case on June 1.
The dispute comes from amended regulations that the Internal Revenue Service issued in 2005 that barred residents who worked at least 40 hours a week—along with their medical educational institutions—from claiming the student tax exemption under the Federal Insurance Contributions Act.
Before the IRS changes, federal law had permitted evaluation on whether the student exceptions applied on a case-by-case basis. This meant reviewing a qualifying school's curriculum, along with a student's relationship to the employer.
AHA says when teaching hospitals and the government have litigated the specific issue about whether medical residents fall within the longstanding definition that keeps in mind their long hours of supervised patient care, "courts appear to have uniformly ruled in favor of the hospitals."
This has meant that that the amended IRS regulation "subjects teaching hospitals to Social Security taxation based upon an arbitrary and immaterial fact," AHA says. Consequently, the practical effect of the amended regulation is to "divert the scarce resources" of the country's "teaching hospitals and medical schools from their crucial missions of patient care, physician training, and medical research."
It also said that although medical residents spend "significant amounts of time" providing patient-care services under the supervision of attending faculty doctors, "the performance of such services is likewise essential to their education."
AHA also notes that since 2004, "the economic climate has simultaneously rendered the myriad services our nation's hospitals provide for their communities all the more 'crucial' and the resources of those hospitals even more 'scarce.'" With the economic downturn, teaching hospitals have become a "critical part of the safety net protecting indigent patients in need of healthcare and health education...while challenging the ability of hospitals to continue providing such protection."
Nationwide, the amount of Social Security taxes levied each year for medical residents is estimated at $700 million. Other friends of the court briefs have been filed in the case this summer by the Association of American Medical Colleges, the American Council on Education, and other universities representing hundreds of residency programs.
With improved drug coverage under Medicare Part D, the use of antibiotics by beneficiaries—particularly brand name, new, and more expensive drugs—is on the upswing, according to a study from the University of Pittsburgh Graduate School of Medicine.
In particular, the study, which appears in the Aug. 9/23 issue of the Archives of Internal Medicine, suggests recent Medicare reimbursement changes in drug coverage improved, for instance, the use of antibiotics for pneumonia. However, this also could lead to unnecessary spending for expensive broad spectrum antibiotics and possible overuse of inappropriate antibiotics.
"Overuse of antibiotics is a common and important problem that can lead to medical complications and drug resistance," said the study's lead author, Yuting Zhang, PhD, assistant professor of health economics at the University of Pittsburgh Graduate School of Public Health.
The study reviewed about 35,000 Medicare beneficiaries and examined their use of antibiotics two years before and after the implementation in 2006 of Medicare Part D, which reduced out of pocket drug spending between 13% and 23%. Increases were seen most among those seniors who did not previously have drug coverage.
Use of the broad spectrum antibiotic subclasses of quinolones and macrolides increased more than the use of other subclasses, especially for those with prior drug coverage.
Researchers said that the use of antibiotic treatment for pneumonia had tripled among seniors who previously lacked drug coverage. They noted that this was encouraging in light of the high mortality associated with community acquired pneumonia among the elderly.
They found, however, increases also in antibiotic use for other acute respiratory tract infections—such as sinusitis, pharyngitis, bronchitis and non specific upper respiratory tract infection—for which antibiotics generally were not indicated.
"Although many interventions have helped curb antibiotic prescribing for acute respiratory tract infections and other conditions, our study indicates there may still be substantial room for improvement through education and changes in reimbursement practices to reduce inappropriate use of these drugs," Zhang said.
Compliance by health insurers with the medical loss ratio provisions in the new healthcare reform law, along with other reforms included in the White House's "Patients' Bill of Rights," may cost those companies more than analysts have predicted, according to research from Weiss Ratings, which provides independent insurance company ratings.
Weiss reported that companies already complying in 2009 had average net profit margins of only 0.7%, while those not yet complying had average net margins of 6.3%—or nine times more.
Starting next year under the new healthcare reform provisions, individual and small group insurers will be required to spend at least 80%--and large group insurers to spend at least 85%--of their premium dollars on medical care and initiatives to improve the quality of care. In addition, insurers renewing on or after Sept. 23 will be required to cover provisions including no arbitrary rescissions of insurance coverage and no lifetime limits on coverage.
"As long as their investment incomes hold up, most large insurers should be able to handle the increased medical expenses expected under the new health care reform," said Martin D. Weiss, president of Weiss Ratings in a statement. "If investment income declines significantly, however, few insurers will be able to comply without debilitating impacts to their bottom line, and ultimately, their financial stability as well."
To view the impact of the reform on the industry's earnings, the Weiss study reviewed 543 health insurers--distinguishing between two groups: 226 not yet compliant companies, or those that spent less than 85% of their premiums on medical expenses in 2009; and 317 "already compliant" companies, or those that already spent 85% or more of their premiums on medical expenses in 2009.
Weiss found that "already compliant" companies including income from both their insurance underwriting operations and from their investments earned a total of $1.74 billion—or an average of $5.5 million each. In contrast, the "not yet compliant" companies earned far more—7.68 billion, or an average of $34 million each.
With underwriting income, the difference between premiums collected and medical claims paid showed sharp differences. Thus as a group, the "already compliant" companies lost $372 million on their insurance operations, with an average underwriting margin of a negative 0.2%; the "not yet compliant" companies earned $6.11 billion with an average underwriting margin of 5%.
The overall size of the insurer was also a factor since larger companies tended to have more investment income--making it possible for them to anticipate higher medical expenses per premium dollar. However, the contrast between the two groups remained great even without the size differences, according to the report.
The adage that says the more things change, the more they stay the same may apply—for better or for worse—to inpatient and physician communications. In a study at a Connecticut hospital, two physicians found that fellow providers who thought they were doing a good job talking and explaining facts to their patients actually found they were falling short of their medical goals.
While much has appeared in the medical literature about how to communicate better with patients, the job is still challenging, physicians say. "Compared to a decade ago patients are sicker, the time they are in the hospital is shorter, and having them involved in their care and getting them to understand their care is increasingly more important and increasingly more difficult," says one of the physicians, Douglas Olson, MD, a chief resident in the primary care program at the 367-bed Waterbury Hospital, private, not-for-profit community teaching facility.
The idea for the study came from the experiences at the hospital of Olson and Donna Windish, MD, MPH,associate program director of the primary care program at Waterbury. "Despite spending time with patients...and despite telling patients why they were in the hospital and telling them what medications they were receiving, we both had the idea that patients just weren't getting it on a daily basis," he says.
"We wondered if this was our own experience or something more of a systemic problem that all physicians are facing," Olson adds. So they decided to see what gaps in understanding existed and in particular how that differed from physician assessments. Their findings appear in the Aug.9 issue of the Archives of Internal Medicine.
They surveyed corresponding internal medicine residents and attending physicians—asking them to report on their care of hospitalized patients and their understanding of their patients' perspectives on the care received. For the study, 89 patients and 43 physicians participated.
What they found was an "impressive disconnect" in the communication and the perceptions of patients and physicians on the care that was provided:
Although 73% of patients thought there was one main physician taking care of them, only 18% were able to correctly name that physician—compared with 67% of physicians who thought patients knew their names.
Most physicians (77%) believed patients knew their diagnoses; however, only 57% of patients said they did.
While 81% of physicians stated that they described adverse effects of medications at least some of the time, only 10% of patients receiving new medications reported being told of any adverse effects.
Although almost all of the physicians stated that they at least sometimes told patients when new medicines are prescribed, only 75% recalled ever being told of these new medications.
Almost all of the physicians stated that they at least sometimes discussed their patients' fears and anxieties, but 54% of patients said they never did this.
So what this means is that "despite the increase attentiveness to involving patients in their care and teaching patients about why they are in the hospital—and they're still not getting the take home message and how it applies to them," Olson says.
This may call for rethinking how to communicate better with patients, he notes. For instance, when patients are admitted to the hospital, they may be told by physicians about the diagnosis, but they usually do not receive written information about that diagnosis, which could help.
Then on discharge, "we give them a lot of instructions that are written, but maybe don't go over things in a very systematic and comprehensive way verbally," he says. "Sort of marrying these two methods of patient communication—the written and verbal—from the moment they hit the door, would be one way of improving patient comprehension."
Also, with increasing use of computer and electronic medical records while the patient was in his or her room, this could help patients learn more about their diagnoses as well, he says.
Getting more involvement with a patient's family also could help greatly when it comes to communication, says Windish, who is also an assistant professor of medicine at Yale, but that has it's own challenges as well in today's medical environment.
In the past, for instance, the hospital residents were likely to be with their patients day and night. But with new work hour limitations coming into place, this is less likely to occur. Similarly, hospitalists have shifts as well. "They are only here for a limited amount of time," she says.
"The problem is that the people who are primarily responsible for taking care of patients are here during the day time—the same time when families are working. So that also limits the communication—particularly if someone is sick and many of the patients in the hospital today have more than one medical issue," she says.
"I think in medical education we're going to need to rethink how to communicate with patients based on more of a team approach," she says. "We need to rethink how inpatient care is given."
With patients admitted to the hospital now being sicker and in for shorter time periods, communication between physicians and patients will remain a challenge, Olson says. "If anything, our results show that we're doing things well, but there's a lot of room for improvement. But as more minds that come to the table about how to improve it, hopefully we'll come out with better solutions."
The Centers for Medicare & Medicaid Services on Tuesday issued final regulations that will implement improvements to the Payment Error Rate Measurement (PERM) for Medicaid and the Children's Health Insurance Program (CHIP).
PERM is designed to detect and measure improper payments made in Medicaid and CHIP and then establish a national-level error rates for each program. The reviews are conducted to determine whether sample cases meet applicable Medicaid and CHIP fee-for-service, managed care, and eligibility requirements. PERM is usually conducted in 17 states annually, so every state typically participates in the program once every three years.
"Like other large federal programs, Medicare, Medicaid, and CHIP are susceptible to errors or improper payments," says CMS Administrator Don Berwick, MD. "Reducing payment errors in federal programs is a key goal of the entire Obama Administration and the rules we are issuing....allow us to implement strategies for reducing the rate of errors in Medicaid and CHIP more effectively."
Taking into consideration comments received from states, advocacy groups, and educational institutions, the final regulation implements changes to programs required by the CHIP Reauthorization Act (CHIPRA) of 2009 and other operational changes.
The rule will change the process for reviewing cases in which states have used simplified enrollment efforts such as self-declaration for eligibility cases.
The final rule does the following:
Eliminates duplication of effort between eligibility reviews administered during the same fiscal year
Extends the timeframe for providers to submit documentation
Provides states with additional time to submit corrective action plans.
As part of the federal-state partnership, CMS will be conducting educational sessions with state oversight staff to promoted better understanding of the changes to the programs established by the final rule. CMS also will work with the states on ways to further reduce payment errors in Medicaid and CHIP.
President Obama signed into law on Tuesday a bill (HR 1586) passed earlier by the House that includes a six-month extension through June 2011 of Medicaid's temporary enhanced Federal Medical Assistance Percentage (FMAP) for the states. FMAP was introduced last year to help financially strapped states pay for additional Medicaid coverage under the economic stimulus package.
The House returned in the midst of its five-week recess to vote for the measure 247 to 161. FMAP runs through Dec. 31 of this year, but many states had been calling for an extension since earlier this year in order to coincide with their state budget planning efforts. The House initially dropped the FMAP provision in its jobs bill approved in May over price tag concerns.
The bill approved by the House on Tuesday scaled back the FMAP increase from the initial 6.2% for six months to 3.2% for the first quarter (January 2011 through March 2011) and 1.2% for the second quarter (April 2011 through June 2011). Those states with high unemployment will continue to receive additional percentage points in funding during the six-month extension.
The cost of the bill is $26 billion, with $16 billion of that going to help states address growing Medicaid budget deficits. Another $10 billion was aimed at providing educational assistance in the states. The Congressional Budget Office said that the bill will reduce the deficit by $1.4 billion.
American Hospital Association Executive Vice President Rick Pollack said in a statement that the FMAP extension would provide "critical relief to states that are struggling to ensure access to care for low-income families and individuals."
These federal matching funds were becoming "even more essential to hospitals in fulfilling their mission of caring for patients and communities," Pollack said. "This funding comes at a crucial time when state budgets are in the red and more people are losing their health care coverage."
Many House Republicans, though, remained critical of the bill. House Minority Leader John Boehner (R-OH) said: "Everyone knows that state budgets have been hit hard and no one wants teachers or police officers to lose their jobs. But where do the bailouts end? Are we going to bail out states next year and the year after that too? At some point we've got to say 'enough is enough.'"
Senators Sheldon Whitehouse (D-RI) and Jack Reed (D-RI) introduced a bill last week that calls for inclusion of mental health professionals and facilities originally excluded from receiving financial incentives for electronic health record (EHR) adoption.
The bill, called the Health Information Technology Extension for Behavioral Health Services Act of 2010, calls for extending eligibility for HITECH financial incentives to behavioral health, mental health, and substance abuse treatment professionals and facilities. It is a companion to the bill (HR 5025) introduced this spring by Rep. Patrick Kennedy (D-RI).
"These providers are the backbone of our mental health care system, and it is vital that they have access to cost-saving, quality-enhancing advances in health information technology," Whitehouse said.
Under the bill, the types of providers eligible for Medicare and Medicaid incentives for the use of EHRs would be expanded to include licensed psychologists and clinical social workers.
The bill calls for:
Expanding Medicare hospital incentive funding eligibility to inpatient psychiatric hospitals
Expanding Medicaid hospital meaningful use incentive funding eligibility to community mental health centers, mental health treatment facilities, psychiatric hospitals, and substance abuse treatment facilities.
Clarifying the eligibility of community mental health centers, psychiatric hospitals, behavioral and mental health professionals, substance abuse professionals, mental health treatment facilities, and substance abuse treatment facilities for technical assistance from Regional Health Information Technology Extension Centers.
Demands for nursing home, assisted living, and home healthcare agencies are expanding rapidly. However, costs for the services can vary widely, according to a report from Univita Health, a Scottsdale, AZ, company that locates and manages resources for this aging population.
Univita Health surveyed more than 2,000 nursing homes, 2,000 assisted living facilities and 2,000 home healthcare agencies nationwide between April and May 2010. Rates obtained included private pay rates for single-occupancy rooms in Medicare-certified skilled nursing facilities, hourly rates for home health aides for Medicare-certified and non-certified home healthcare agencies, and monthly rates for assisted living facilities.
The average annual cost nationwide of a private room in a Medicare-certified skilled nursing facility (SNF) for all regions surveyed in this study was $90,155. Meanwhile, the average daily rate for a single occupancy, private room in a Medicare-certified SNF was $247.
Also, the average monthly rate for a private, single occupancy room in an assisted living facility was $3,294.67 per month, while the average monthly rate for a semi-private room in an assisted living facility was $2,025.28 per month.
Among other findings are:
The national average hourly rate for home health aides provided by a certified home health care agency was $22.14 per hour.
The national average hourly rate for a home health aides provided by a non-certified home health care agency was $18.41 per hour.
The region with the most expensive daily average rate for a private, single occupancy room in a Medicare-certified skilled nursing facility was Anchorage, AK, and costs $576 per day.
The region with the least expensive daily average rate for a private, single occupancy room in a Medicare-certified skilled nursing facility was Lafayette, LA, and costs $143 per day.
The region with the highest average hourly rate for home health aides provided by a certified home health care agency was Stamford, CT at $34.85 per hour.
The region with the lowest average hourly rate for home health aides provided by a certified home healthcare agency was Shreveport, LA, with a cost of $14.50 per hour.
The region with the highest average hourly rate for home health aides provided by a non-certified home health care was agency is San Francisco, at $24.70 per hour.
The region with the lowest average hourly rate for home health aides provided by a non-certified home health care agency was Brooklyn, NY, with a cost of $11.90 per hour.
A second federal bill seeks to "clarify the application of EHR payment incentives" for multi-campus hospitals in the meaningful use subsidy requirements issued by the Centers for Medicare & Medicaid Services.
Sen. Charles Schumer (D-NY) introduced S. 3708, the Electronic Health Record Incentives for Multi-campus Hospitals Act, late last week. The bill would amend the Social Security Act to "clarify the application of EHR payment incentives" for multi-campus hospitals.
Schumer's bill follows on the heels a week earlier of the similar bill introduced in the House by House Ways and Means Health Subcommittee Chairman Pete Stark (D-CA), Rep. Zack Space (D-OH), Energy and Commerce Health Subcommittee Chairman Frank Pallone (D-NJ), and Rep. Michael Burgess (R-TX).
Both bills would eliminate the provision in the meaningful-use subsidy requirements issued by the Centers for Medicare &; Medicaid Services. This provision treats multi-campus hospitals as a single unit, thereby capping the subsidy it can receive without recognizing the "incremental acquisition, training, and implementation costs" they incur, as the House bill states.
In a letter, the American Hospital Association (AHA) said the Schumer bill it would that would make clear the intent of the Health Information Technology for Economic and Clinical Health" (HITECH) Act—passed as part of the American Recovery and Reinvestment Act of 2009—to provide payment incentives in an equitable way to individual hospitals that are part of multi-campus hospital systems."
The letter further stated that the "bill would ensure that payments would be available to all hospitals in a multi-campus system, and that these hospitals could choose the calculation that would best meet the needs of their institutions and communities, either through additional base payments or additional per discharge amounts."
In testimony, before the House Energy and Commerce Committee last month, a CMS official told the panel that while CMS had received many comments and requests to recognize each campus of a multi-campus hospital in regard to the incentive payments, hospitals should not anticipate additional incentive payments beyond what would be paid for one hospital under the "meaningful use" provisions unveiled earlier that month.
