Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
Catholic and other church-owned health systems were more likely to provide higher quality performance to the communities they served than secular, not-for-profit health systems, according to a study from Thomson Reuters.
To assess the effects of ownership type on performance, Thomson Reuters analysts assigned 255 hospitals reviewed in its "100 Top Hospitals: Health System Benchmarks" study to one of four ownership categories: Catholic, other church, investor-owned, and not-for-profit. Those hospitals with missing ownership information were assigned to the "unknown" category.
Some of the healthcare systems were highly centralized—located in the same state or the same market area, while other systems had hospitals widely dispersed across multiple states or regions. In addition, the number of hospitals in each system could deviate widely.
To compensate for these differences, the researchers used the number of hospitals in each system as a variable to create a weighted average for the system performance. Using the rankings for system performance from the Health System study, a mean performance rank was calculated for each of the five ownership groups.
Overall, Catholic and other church-owned systems were listed first and second respectively in terms of being significantly more likely to provide higher quality performance and efficiencies to communities than investor-owned systems. Investor-owned systems demonstrated lower quality performance than all other groups.
"The findings of the study suggest a changing role for health system governance and leadership," says Jean Chenoweth, senior vice president for performance improvement and 100 Top Hospitals programs at Thomson Reuters. "Our data suggest that the leadership of health systems owned by churches may be the most active in aligning quality goals and monitoring achievement of mission across the system."
The findings also imply a changing role for health system governance and leadership, according to the report. Many health systems were founded for economic purposes—such as access to capital, economies of scale, increased market share, and greater negotiating power with payers. Therefore, the responsibility for quality of care in most health systems could fall to local hospital governing boards.
This means that the leadership teams including boards, executives, and physician and nursing leaders of health systems owned by churches may be more active in aligning quality goals and watching achievement across the system, the report says.
Further study will be needed to better determine why these differences among systems exist and what impact they will have on the systems' future health—especially in light of changes expected with healthcare reform, it added. Researchers at the University of Michigan, School of Public Health currently are assessing this area.
The Health System Benchmarks study, which was released earlier this summer by Thomson Reuters, relied on public data from the 2007 and 2008 Medicare Provider Analysis and Review (MedPAR) data and the Centers for Medicare and Medicaid Services Hospital Compare data sets.
During the past four months, healthcare reform legislation has been a shining light on the need to improve preventive care and primary care services for those in need. Who can really argue about this quest to provide quality care? But, a nagging feeling exists that many Americans need more to reach their "unrealized health potential."
In a commentary out this week from Health Affairs, several prominent health policy experts revisit the idea of how the culture of care may influence healthcare delivery more than many people may admit. They draw their discussion in part from recommendations issued a year ago from the Robert Wood Johnson Foundation's Commission to Build a Healthier America on "New Directions to a Healthier America."
The commentators note that there is no question "that medical care is essential for relieving suffering and curing illness." However, medical care prevents only 10% to 15% of premature deaths, they say. Instead, research shows that social (and cultural) factors—including education, income, and the quality of neighborhood environments—play a prominent role "in shaping our health than medical care does," they write.
For instance, college graduates can expect to live five years longer than those who don't complete high school. And, if everyone enjoyed the same good health as college graduates, the national economy would achieve an annual average savings of $1 trillion, they say. At the same time, longer and healthier lives would result in higher workforce productivity, reductions in expenditures on social programs and increases in tax revenues.
Mark McClellan, MD, PhD, the former head of the Centers for Medicare & Medicaid Services, said a year ago when the report was released:
"The evidence is clear that how we live, learn, work, and play has a much greater influence over how well and how long we live than our healthcare,"
"It's time to take a wider view of what we need to do to improve our health," says McClellan, who is now director of the Engelberg Center for Health Care Reform at the Brookings Institution in Washington.
So, what needs to go on outside the medical system to help improve healthcare in the future? The experts make a number of suggestions, based on the work of the commission, to promote a national culture of health which include:
Designing public programs that support the needs of hungry families for nutritious foods.
Eliminating smoking and promoting a smoke-free nation.
Giving children, especially those from low-income families, a healthy start by ensuring that they have high-quality education and child care.
Getting children to be physically active at least an hour every day.
Banning junk food from schools.
As the commentators note, new inroads are being made in some of these areas. For instance, at the federal level, new cooperative health efforts are being undertaken—such as seen with a recent announcement by the Department of Health and Human Services of a $650 million community prevention and wellness initiative to promote more physical activity, better nutrition, and reductions in obesity and smoking.
And, more publicly, the challenge has given rise to First Lady Michelle Obama's "Let's Move" campaign, which aims to end the epidemic by increasing understanding of nutrition, encouraging schools to provide healthier food, and promoting physical
activity.
So it's a start. While advances in medicine are important, when it comes to population health, it's our actions and choices that will make the biggest difference in the quality of our health lives.
In 2009, 76% of all specialties saw an increase in compensation, with the overall weighted average increase of approximately 3.4%. The primary care specialties' (excluding hospitalists) average compensation increase was about 3.8%, according to the American Medical Group Association's (AMGA) 2010 Medical Group Compensation and Financial Survey.
Other medical specialties had on average a 2.4% increase, and surgical specialties had a 3.8% average increase.
Between 2008 and 2009, the specialties reporting the largest increases in compensation were pulmonary disease (10.37%), dermatology (7%), urology (6.36%), family medicine (5.67%), hypertension and nephrology (5.54%), and cardiac and thoracic surgery (5.12%).
"The modest increases seen this year reflect the negative impact of declining reimbursements, competition for specialists, the cost of new technology, and other factors on practice revenues in most parts of the country," says AMGA President and CEO Donald Fisher, PhD.
For work relative value units (RVUs), the overall weighted average increase from 2009 to 2010 was approximately 0.8%. For the specialties reviewed by AMGA, the average increase in work RVUs was 1.2% from 2009. Primary care remained flat, other medical specialties increased by 2.7%, and surgical specialties increased by 3.0%, on average. The largest work RVU increases occurred in cardiac and thoracic surgery and otolaryngology.
For gross charges, 65% of the specialties experienced an increase from 2009 to 2010. The overall weighted average increase from 2009 was approximately 2.5%. Gross charges for primary care specialties increased by 4.1% on average, while other medical specialties increased by 1.3% and surgical specialties by 5.6%, on average.
The survey noted that many medical groups were still encountering significant financial challenges. While most regions looked healthier than in 2008, margins were still thin. In 2009, for instance, organizations in the Eastern and Western regions were operating at a break-even point.
Many of the losses seen in 2009 were supplemented by other non?clinical revenue sources and funding from health systems with which groups are associated, Fisher said. Most of the medical groups represented in the survey were part of larger organized systems of care that have made investments in technology, operations, and other care processes, he added.
The 2010 AMGA Medical Group Compensation and Financial Survey was sent to more than 2,700 medical groups. Survey responses were received from 248 groups, representing more than 49,700 physicians and 121 specialties.
Researchers with The Commonwealth Fund report the healthcare reform law will "stabilize and reverse" the growing healthcare costs faced in the past decade by 15 million women who are uninsured and 14.5 million women considered underinsured.
"This new law marks a dramatic departure from the past in women's ability to gain affordable and comprehensive health insurance coverage," said Commonwealth Fund Vice President Sara Collins in a telebriefing.
While women are just as likely to be uninsured as men, their healthcare needs often leave them more vulnerable to high healthcare costs and problems related to loss of health insurance, Collins says.
For instance, an estimated 7.3 million women (38%) who tried to buy health insurance in the individual market in the past three years were turned down, charged a higher premium, or had their condition excluded from their health plan because of a pre-existing health condition. Currently, rating on the basis of gender is permitted in the individual market in 42 states—with some plans charging as much as 84% more for women than men in the same age group for the same insurance policy, the report notes.
This will change by January 2014 when all insurance carriers are required to accept every individual who applies for coverage (guaranteed issue and renewability), and are prohibited from charging higher premiums on the basis of health status or gender. Premiums can reflect age, but cannot vary by more than a ratio of three-to-one.
"While 18% of women are uninsured nationally, the rate is higher than that in 17 states, so women in those states stand to make substantial gains in coverage as a result of that expansion," Collins says.
Women living in states with higher than average uninsurance rates, stand to gain the most from the new law: New Mexico and Texas (29% uninsured in 2008); Florida and Louisiana (24% uninsured); and Alaska, Arizona, Arkansas, California, Georgia, Mississippi, West Virginia, Idaho, Kentucky, Nevada and Oklahoma (at least 20% uninsured).
In an analysis of health insurance plans sold in the individual market, the National Women?s Law Center found that just 13% of the plans studied included maternity benefits—though substantial variation was found across states, according to the report.
All health plans in Massachusetts, New Jersey, and Oregon were found to include maternity benefits, but 22 states reported no plan-covered costs related to pregnancy. Also, other studies have shown that when individual market plans do include maternity benefits, they often severely limited in the amount of costs covered or have long waiting periods before coverage begins.
Beginning in 2014, all health plans sold through the new state insurance exchanges, as well as the individual and small?group markets, will be required to include coverage of maternity and newborn care, as part of a federally determined essential benefits package.
Grandfathered plans or those in existence on March 23, 2010 in those markets will not have to comply with that standard. Instead, the benefits package will be similar to packages offered through employer plans and will include:
ambulatory patient services;
emergency services;
hospitalizations;
mental health and substance use disorder ser vices, including behavioral health;
More than 1,600 registered nurses at the 900-bed Washington Hospital Center, the largest non-profit hospital in the Washington, DC, area, prepared Friday to vote over the weekend on whether to go on strike. At issue is the hospital's decision last winter to fire 18 nurses and discipline several more following severe snow storms in the region.
Following a membership meeting on Thursday, the nurses prepared for onsite voting throughout the weekend on whether they would stage a one-day work stoppage. The action coincides with the arrival of a new president (John Sullivan) this week, and the recent departure of the hospital's senior vice president for human resources and the chief nursing officer.
"It is long past time for the hospital to right these wrongs," says Dottie Hararas, RN, president of Nurses United of the National Capital Region.
The nurses union is asking that the dismissed nurses be brought back. If that were to occur, the strike would be cancelled, they said.
If the nurses vote to strike, they would stop work on a selected date for a 24-hour period. The result of the nurses' one-day strike vote is expected to be announced Monday.
At issue are registered nurses who were dismissed and disciplined in February and March after they failed to report to work during multiple blizzards in February that shut down area governments and businesses for more than a week. Hospital officials said at the time that they provided transportation for the nurses and also alerted staff beforehand that they should make accommodations—such as staying at the hospital—when the storm hit.
Recent discussions about how electronic health records can improve healthcare delivery mainly have focused on the impact on hospitals, physicians, or nurses. Missing from this lineup: patients. A one-year pilot called OpenNotes, however, is aiming to get patients more involved in their care by letting them read their primary care physicians' visit notes online through secure Websites.
"Patients say that they're really interested in this by and large. But, one of the questions is if we open these records, will they look at them?" says Jan Walker, RN, MBA, a health services researcher at Beth Israel Deaconess Medical Center, Boston, and one of the study's lead investigators. "So thanks to computer systems, we can find out."
The study, outlined in the July 20 Annals of Internal Medicine, involves about 100 primary care physicians—who volunteered for the OpenNotes project—at three diverse organizations: Beth Israel Deaconess, an urban academic health center with community practices; Geisinger Health System, an integrated health system in rural Pennsylvania; and Harborview Medical Center, a county hospital in Seattle which serves many homeless and indigent patients.
About 30,000 patients—members of their physicians' panels--are expected to participate during a one-year period. Patients of participating physicians are alerted by e-mail when their physicians' notes are available.
Beth Israel and Geisinger, which started their OpenNote initiatives in May and July respectively, have secure, established electronic portals. Harborview Medical Center will offer its patients access to a secure online portal for the first time in September.
As expected, quite a few primary care physicians approached about the OpenNotes project expressed reservations. At the top of the list of their concerns was the effect on their time—particularly if overwhelming numbers of patients would contact them through phone calls, letters or e-mails if they had questions or comments.
Other physicians thought they would have to write notes that would be scientifically imprecise—leaving out important diagnostic and therapeutic considerations—in order to be understood by patients. Other physicians noted that they were embarrassed by their writing or uncomfortable with their typos--making them seem less professional, the researchers found.
And then, then there were those abbreviations that were confusing or likely to draw their patients' ire—such as "SOB," which in a clinical context means "shortness of breath."
Others are looking at OpenNotes as a way for patients to get something extra out of their care. Another researcher who assisted with the study, Henry Feldman, MD, says, "I wanted to do this because in Massachusetts—for a long time—we've had this rule that patients should have access to their healthcare records, but we make it very hard for them."
Feldman, who currently holds dual appointments as a hospitalist and as the chief information architect with the Division of Clinical Informatics at Beth Israel, says the "most underutilized resource" in the healthcare system is the patient.
"I think [patients] should be put to work a little bit...but not in a bad way. If you put them to work, they become engaged in their healthcare," he says. Right now, healthcare is often viewed by patients as something that "you go to and you get"--akin to going to a movie where you watch and walk out.
"You don't get involved in the process. You're a passive observer," he says. Making physicians' visit notes available might change this.
"Right now patients have no idea what goes into theirhealthcare. Study after study has shown that patients don't retain what we tell them in a visit," he adds. With a combination of shorter medical visits and overwhelmed patients, sometimes the discussions—about medications, symptoms, or tests—may be cut short.
Viewing physician notes may help them understand better what is going on—and may help physicians as well. "[Patients] may go into their notes, and they can actually see it: [how to] help me help them—which to me is an exciting concept," he says. "I'm not trying to solve all of society's ills, but if I can get a patient to help me help them, they'll get better care."
The results of this study, which is being funded by a grant from the Robert Wood Johnson Foundation, are another year off: The researchers will use pre- and post-viewing surveys to gauge the reactions of both physicians and patients.
For most patients at Beth Israel and even Geisinger, many patients have become familiar with using an electronic portal. "They're used to getting notified [online so] this isn't a radical shift from an infrastructure standpoint," Feldman says.
But from a relationship standpoint, "this is a disruptive technology," he quips. "For the first time, we're letting patients see behind the mask." While patients may be "underwhelmed" in the long run, "I hope it's going to spark them to become engaged—at least to try and figure out what the gobbledygook was that we wrote in the chart."
A top competition priority this year at the Federal Trade Commission (FTC) is to stop "pay-for-delay" agreements between branded and generic drug manufacturers, FTC Chairman Jon Leibowitz told the House Judiciary Subcommittee on Courts and Competition Policy on Tuesday.
According to newly released agency data, branded and generic drug companies entered into 21 "suspect patent litigation settlements" involving compensation in the first nine months of fiscal 2010 alone. This surpassed the total for all of fiscal 2009, he said.
Those settlements are assigned to "protect" $9 billion in prescription drug sales, said Leibowitz, citing an earlier FTC report. They also delay the availability of cost-saving generics by an estimated 17 months.
At the same time, the settlement filings confirm that brand and generic companies have been settling their disputes without brand companies paying their generic competitors not to compete: 75% of all final patent settlements did not involve compensation from the brand company to the generic, combined with a delay in generic entry, the report said.
"That's almost an epidemic," Leibowitz said, "Left untreated, these types of settlements will continue to insulate more and more drugs from competition. Every single FTC commissioner—going back through the Bush and Clinton administrations?has supported stopping these unconscionable agreements."
The tide, though, on these cases may be turning around," Leibowitz said. A few months ago, an appellate panel in the Second Circuit, which had previously adopted a permissive approach to pay-for-delay settlements, took the step of questioning its own standard and explicitly encouraged consumer plaintiffs to request the court's re-consideration of the pay-for-delay issue.
Both the FTC and the Justice Department filed briefs with the Second Circuit advocating that the full court revisit this issue. In another development in March 2010, a federal district court judge in Philadelphia denied a defense motion to dismiss the Commission's case against Cephalon. That case is now in the discovery phase.
Multi-campus hospitals should not anticipate additional incentive payments beyond what would be paid for one hospital under the "meaningful use" provisions unveiled earlier this month. That was the testimony of a Centers for Medicare & Medicaid Services executive before a House Energy and Commerce Health Subcommittee during a hearing on the HITECH Act Tuesday.
Tony Trenkle, director of the Centers for Medicare & Medicaid Services' Office of eHealth Standards and Services, told the House panel that CMS had received many comments and requests to recognize each campus of a multi-campus hospital in regard to the incentive payments made for electronic health record adoption. These are hospitals that use the same CMS certification number.
"We understand that this issue is of importance to members of Congress, the hospitals, and the public. However, from the agency's perspective, we believe it's important to treat hospitals consistently," Trenkle said.
"The decision to deviate from long-standing hospital policy in this particular instance—without clear statutory direction to do so—would have made CMS vulnerable to legal challenges."
He said that when CMS looked at the legislative language of the stimulus legislation which authorized the EHR incentive initiative. "We came to the conclusion in our final rule that we should define hospitals consistently for all policy purposes, including the Medicaid & Medicare EHR incentive payments."
This decision could seriously impact a number of hospitals, several congressman on the panel told Trenkle. Rep. Zack Space (D-Ohio) said that in his district, for instance, Genesis Healthcare in Zanesville, OH, stands to lose $2 million in incentive payments based on the current rule.
"As you might understand, we're a little frustrated by that rule," Space said. He asked if decisions like this would ultimately make it more difficult for hospitals, such as Genesis, to adopt the technology that the law is designed to promote."
Trankle said that CMS based its payment decision on existing policy. "The provider number is based on how the hospitals choose to organize themselves for payment under Medicare program. So, what we did here—without clear statute intent—was to be consistent with payment policies that we have adopted for other programs."
Trenkle acknowledged that CMS had met with interested stakeholders, including the two largest hospital associations, the American Hospital Association and the Federation of American Hospitals, to hear their concerns. However, he said, CMS would not reconsider its decision at the current time.
As the nation's population continues to grow and diversify, the healthcare system still needs to change and adjust to meet the needs of an increasingly multicultural patient base, according to the American College of Physicians (ACP) in an updated paper released Monday.
Racial and Ethnic Disparities in Health Care, a revision to a policy paper that was originally released in 2003, looks at what further steps are needed to close the gap between racial and ethnic minority patients and their white counterparts.
"Closing the healthcare disparities gap will be a difficult, multifaceted, and important task," said J. Fred Ralston, Jr, MD, president of ACP, in a statement. "Overwhelming evidence shows that racial and ethnic minorities continue to be prone to poorer quality health care than white Americans, even when factors such as insurance status are controlled."
As the nation's population diversifies, one area of concern is cultural competency, which will become more important as clinicians are confronted with different belief systems that "influence their ability or patient receptivity to provider recommendations," the report states.
While only half of all patients generally adhere to medical or prescription instructions offered by clinicians, rates of adherence are significantly lower for racial and ethnic minorities, according to the report. Cultural competency is a key part of delivering patient-centered care that stresses "respect for the patient, clear communication, shared decision making, and building of the doctor-patient relationship."
Communication barriers—particularly language barriers—are a significant problem for many physicians, especially those who provide care frequently to Medicaid and other public insurance program beneficiaries. In one survey, 63% of hospitals and 54% of internal medicine physicians reported treating "limited English proficiency" patients at least weekly, and 84% of federally qualified health centers cared for these patients daily.
According to one ACP survey, internists reported seeing limited English proficiency patients speaking nearly 80 dialects and languages. Even after the influential 2002 IOM report "Unequal Treatment" highlighted the difficulties of communication between physicians and other health providers and patients with limited English proficiency, the problem has worsened among some groups.
To address this problem in part, all payers should provide funding for linguistic and interpretive materials and personnel. Currently, few private insurers cover the cost of language services, and Medicare does not reimburse for interpreters, the report noted. Only 12 states and the District of Columbia provide funding for interpreters for Medicaid and Children's Health Insurance Program beneficiaries.
In updating the recommendations from the previous policy paper's call to action, ACP also calls for:
All legal residents should be provided with affordable health insurance.
The healthcare delivery system must be reformed to ensure that patient-centered medical care is easily accessible to racial and ethnic minorities, and physicians are enabled with the resources to deliver quality care.
Diversity in the healthcare workforce must be encouraged.
Inequities in education, housing, job security, and environmental health must be erased if health disparities are to be effectively addressed.
Efforts must be made to reduce the effect of environmental stressors that disproportionately threaten to harm the health and well-being of racial and ethnic communities.
More research and data collection related to racial and ethnic health disparities is needed to empower stakeholders to better understand and address the problem of disparities.
Racial and ethnic disparities in healthcare present a difficult challenge that results from the interaction of multiple complex factors, for which there are no easy solutions," Ralston adds. "However we as physicians, and as a society, have a moral imperative that appropriate resources are devoted to responding to the challenge."
While the new healthcare reform law calls for significant changes to the payment process for care delivered under Medicare, that information has not been effectively filtering down to the major beneficiaries of that care.
According to a survey released by the National Council on Aging (NCOA) on Monday, many seniors appeared to not know how the law would be impacting their healthcare.
For the survey conducted by Harris International two weeks ago, none of the 636 senior adults interviewed knew the correct answers for all 12 of the key reform-related questions selected by NCOA. "Very few Americans age 65 or older say they are even familiar with the law at call," said David Krane, Harris Interactive's vice president of public affairs and policy research, who spoke at a briefing in Washington.
The poll revealed that only 17% of seniors knew the correct answers to more than half the factual questions posed about key aspects of new law, and only 9% knew the correct answers to at least two?thirds of the questions. Krane said.
For instance, for the question on whether the healthcare reform law will cut Medicare payments to physicians, more than half of those polled—who said they were very familiar or somewhat familiar with the law—agreed incorrectly that the reform law will cut payments to physicians. For those who said the Medicare payment cuts would not be impacted by the reform law, 24% and 16% respectively said they were familiar with the law.
In regard to quality of care, a point consistently emphasized through the year-long healthcare debate in Congress—more than half incorrectly agreed with the question. Many believed the law did "not improve the quality of care" for Medicare beneficiaries with chronic illnesses, such as diabetes and high blood pressure.
In addition, with the federal budget deficit looming over the policy debates, only 14% of seniors said they were aware that the new law is projected to reduce the deficit. Many (49%) believed incorrectly that it would increase the deficit over the next decade. (According to projections by the Congressional Budget Office, the law will reduce the deficit by an estimated $124 billion over 10 years).
"The survey calls out for more education about the subject [of Medicare and healthcare reform], which is obviously very complicated," Krane said. Among other findings in the survey are:
Only 24% of seniors knew that it is projected to extend the solvency of the Medicare Trust Fund.
Only 28% knew that the law improves the availability of long?term care at home for seniors with disabilities.
Only 33% knew about the new, free yearly wellness visit Medicare will now provide.
Two out of three seniors either did not know (43%) or gave the wrong answer about the future growth of Medicare spending.
The seniors' highest rate of correct answers came on a question about whether the law expands coverage to 32 million uninsured Americans (43% correctly answered "yes"). Seniors also showed relatively high awareness of the provision to gradually close the Medicare prescription drug coverage gap, 42% gave the correct answer.
James Firman, president and CEO of NCOA, announced on Monday the launch of NCOA's "Straight Talk for Seniors on Health Reform" campaign, which is aimed at helping seniors obtain the facts they need about healthcare reform and changes to Medicare.
"Seniors need to know the key facts about health reform so that they can be informed consumers and educated citizens," Firman says. The campaign will continue through the fall with additional town hall and educational events, a series of "Straight Talk" educational materials, and an interactive online "Straight Talk" quiz for people to test their knowledge of the law.