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ONLINE EXCLUSIVE: Listen to former Obama healthcare advisor Bob Kocher, MD
Click here to listen to Dr. Kocher
Click here to listen to Dr. Kocher
Click here to listen to Dr. Kocher
POLICY CORNER: Despite significant QI, disparities among poor Americans persist.
The Agency for Healthcare Research and Quality (AHRQ) recently released the annual National Healthcare Quality & Disparities Reports. The reports provide in-depth quality information on the overall population and divide this information along such subgroups as race, ethnicity, and education level. The report is more than 200 pages long, but it can be summarized in one sentence: If you are poor, the quality of your healthcare is likely to be poor.
Despite significant quality improvement (QI) in a number of areas, disparities among poor Americans persist. For example, the percentage of heart-attack patients who underwent procedures to unblock heart arteries within 90 minutes improved to 81% in 2008 from 42% in 2005. This is very positive news, but unfortunately, these and many other gains in quality only apply to higher-income populations.
A new section of the report focused on care coordination and transitions of care contains some statistics of particular interest to hospitalists. One statistic shows that the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions improved to 82.0% in 2008, up from 57.5% in 2005.
It is important to note that this number remains more or less constant across all racial/ethnic divisions. Could part of this improvement be attributed to the growth and success of the hospitalist movement?
Hospitalists know that despite the numbers, a successful transition does not simply include discharge instructions; it is the combination of those instructions, along with coordination with primary care, that prevents avoidable readmissions.
Unfortunately, 15% to 20% of low-income patients have no regular primary-care physician (PCP). If a condition begins to deteriorate, this group often has little choice but to return to the hospital.
In the absence of a PCP, it is the hospitalist who can provide patients with the tools they need to stay healthy after leaving the hospital.
Such assistance can range from ensuring that patients truly understand their discharge instructions to being a resource for future questions. Hospitalists are ahead of the game when it comes to quality and reducing disparities; it is just a matter of the other facets of healthcare catching up.
The National Healthcare Quality & Disparities reports are available at www.ahrq.gov/qual/qrdr10.htm. TH
The Agency for Healthcare Research and Quality (AHRQ) recently released the annual National Healthcare Quality & Disparities Reports. The reports provide in-depth quality information on the overall population and divide this information along such subgroups as race, ethnicity, and education level. The report is more than 200 pages long, but it can be summarized in one sentence: If you are poor, the quality of your healthcare is likely to be poor.
Despite significant quality improvement (QI) in a number of areas, disparities among poor Americans persist. For example, the percentage of heart-attack patients who underwent procedures to unblock heart arteries within 90 minutes improved to 81% in 2008 from 42% in 2005. This is very positive news, but unfortunately, these and many other gains in quality only apply to higher-income populations.
A new section of the report focused on care coordination and transitions of care contains some statistics of particular interest to hospitalists. One statistic shows that the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions improved to 82.0% in 2008, up from 57.5% in 2005.
It is important to note that this number remains more or less constant across all racial/ethnic divisions. Could part of this improvement be attributed to the growth and success of the hospitalist movement?
Hospitalists know that despite the numbers, a successful transition does not simply include discharge instructions; it is the combination of those instructions, along with coordination with primary care, that prevents avoidable readmissions.
Unfortunately, 15% to 20% of low-income patients have no regular primary-care physician (PCP). If a condition begins to deteriorate, this group often has little choice but to return to the hospital.
In the absence of a PCP, it is the hospitalist who can provide patients with the tools they need to stay healthy after leaving the hospital.
Such assistance can range from ensuring that patients truly understand their discharge instructions to being a resource for future questions. Hospitalists are ahead of the game when it comes to quality and reducing disparities; it is just a matter of the other facets of healthcare catching up.
The National Healthcare Quality & Disparities reports are available at www.ahrq.gov/qual/qrdr10.htm. TH
The Agency for Healthcare Research and Quality (AHRQ) recently released the annual National Healthcare Quality & Disparities Reports. The reports provide in-depth quality information on the overall population and divide this information along such subgroups as race, ethnicity, and education level. The report is more than 200 pages long, but it can be summarized in one sentence: If you are poor, the quality of your healthcare is likely to be poor.
Despite significant quality improvement (QI) in a number of areas, disparities among poor Americans persist. For example, the percentage of heart-attack patients who underwent procedures to unblock heart arteries within 90 minutes improved to 81% in 2008 from 42% in 2005. This is very positive news, but unfortunately, these and many other gains in quality only apply to higher-income populations.
A new section of the report focused on care coordination and transitions of care contains some statistics of particular interest to hospitalists. One statistic shows that the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions improved to 82.0% in 2008, up from 57.5% in 2005.
It is important to note that this number remains more or less constant across all racial/ethnic divisions. Could part of this improvement be attributed to the growth and success of the hospitalist movement?
Hospitalists know that despite the numbers, a successful transition does not simply include discharge instructions; it is the combination of those instructions, along with coordination with primary care, that prevents avoidable readmissions.
Unfortunately, 15% to 20% of low-income patients have no regular primary-care physician (PCP). If a condition begins to deteriorate, this group often has little choice but to return to the hospital.
In the absence of a PCP, it is the hospitalist who can provide patients with the tools they need to stay healthy after leaving the hospital.
Such assistance can range from ensuring that patients truly understand their discharge instructions to being a resource for future questions. Hospitalists are ahead of the game when it comes to quality and reducing disparities; it is just a matter of the other facets of healthcare catching up.
The National Healthcare Quality & Disparities reports are available at www.ahrq.gov/qual/qrdr10.htm. TH
The GOP Viewpoint
A two-time cancer survivor and obstetrician who has delivered thousands of babies, U.S. Sen. Tom Coburn (R-Okla.) has a unique perspective on healthcare as a provider, recipient, and influential advocate for change. Minutes after voting to repeal the Patient Protection and Affordable Care Act of 2010—an effort that ultimately failed in the Democratic-controlled Senate—Dr. Coburn talked with The Hospitalist about his objections to the existing law, his views on the main drivers of upwardly spiraling healthcare costs, and the Republican Party’s alternatives for achieving the elusive goals of better quality and cost control.
Question: What are your main concerns about the healthcare reform law?
Answer: I think, first of all, the healthcare reform bill doesn’t fix the problem, and the question is, what is the problem in healthcare in America? Is it quality, is it outcome, is it access, or is it cost?
And the problem is we spend twice as much per capita as anybody else in the world on healthcare to get 30% better outcomes on average. So the problem with healthcare in our country is it costs too much, and there’s a lot of reasons it costs too much. But the number-one reason is that everybody in the country, except those without insurance, thinks somebody else is paying their bill. So there’s no consumer discretionary choices that are made once you’ve met your deductible.
Having practiced for a long period of time and cared for the Amish, they always bought healthcare about 40% to 60% less than everybody else, because they pay cash for it and they deal [with] it, and they ask, “Why am I having this test?” and “Where can I get this test done more cheaply?” and “Are you sure I need this test?”
Being trained in the early 1980s and late ’70s as a physician, we’re trained different than the way doctors are trained today. Doctors today don’t think a thing about utilization. … What this bill did was expand coverage but didn’t fix the system, except that Washington’s now going to tell your hospitalists who they’re going to treat, how they’re going to treat them, and when they’re going to treat them.
Q: How do we fix the right problem?
A: You have to reconnect the purchaser with the payment; that’s No. 1. No. 2 is, you cannot continue to allow people to think somebody else is paying their bill, even when they’re not. If you work for a large company or you work for the government, the fact is, you’re paying money out every year for your portion of the coverage, and your employer is paying it out. They’re paying, in most instances, the vast majority of it, and so once you’ve met a deductible, you’re no longer a discretionary consumer because your assumption is, it’s going to get paid for.
And the other side of this is, how do we put in the doctors’ hands cost consciousness? In other words, can I do this and get the same outcome without spending this money? And quite frankly, we’ve trained a generation-and-a-half of physicians not to think about that.
Q: How else can we reduce costs?
A: It’s amazing what could happen if we start driving toward cost reduction. We have veterans who have to drive … to get to a VA. Give the veteran a card. If you’re service-connected, you can go wherever you want. Why should a veteran only be able to get access at a veterans’ healthcare center where the care isn’t as good, the outcomes aren’t as good, when they can go in their own hometown and buy something that’s better? So, you know, it’s about real freedom of choice and it’s about letting markets allocate scarce resources.
We’ve got a whole host of things that we’ve talked about on how to do this. The [Patients’ Freedom to Choose Act], it saves the states billions in terms of cost.
Q: Do you have any optimism that Congress can work together in a bipartisan way to address some of your concerns with the existing law?
A: No. This isn’t fixable in the way that they have it. To make this fixable, you have to take out the individual mandate, you have to take out the employer mandate, and you have to go to a system of risk reallocation on the insurance industry. If you want to really cover people with pre-existing illnesses, what you have to do is keep the insurance industry from cherry-picking. And what they tried to do is to get everybody covered so you could actually indemnify the whole population.
Our other problem is we’re spending money. You know, if we spent a lot of money on prevention that actually worked, we would in fact save some dollars. But we haven’t created a situation where the insurance industry is interested in keeping you as a long-term insuree, so, therefore, I don’t have any incentive to work on your wellness. Now they’re doing a little bit of that, but they’re not to a great extent. And if you knew you could buy your health insurance over a period of 20 years and be with the same company and they’d actually help teach you, get the things that are going to lower your risk and your cost, they’d both save money.
So there are all sorts of things, but what we’ve done is we’ve abandoned the thing that we use in the rest of the country to allocate scarce resources, and that’s market forces. Ask yourself why the best hospitalists in the country get paid the same as the worst. Well, why wouldn’t we want to incentivize and pay for higher quality and pay less for poorer quality and poorer outcomes, to the point where we promote excellence rather than mediocrity? But we don’t do that.
Q: What’s the next step for Republicans in trying to push forward some of your own ideas?
A: We’re going to take our [Patients’ Freedom to Choose Act] and we’re going to modify it somewhat and we’re going to introduce it and have, you know, “Here’s what we believe. You all believe this, we believe in individual freedom and personal responsibility and accountability,” and we’re going to try to do that. That won’t go anywhere because we don’t have the votes to have it go anywhere. What we’re going to wait for if the court cases. My suspicion is the president loses the court case when it gets to the Supreme Court.
Q: Do you believe the entire act will be struck down or just the individual mandate?
A: No, no. I think the entire act will be struck. The bill doesn’t work without the individual mandate because you don’t get enough revenues in to cover what—and the bill is scored so stupidly anyhow. I don’t know if you know much about government budgeting, but this thing’s a farce in terms of its cost. It’s going to cost fully $600 billion to a trillion dollars more in the first year [2014] than they’re saying it will.
Q: What’s your view on accountable-care organizations?
A: Accountable-care organizations (ACOs) aren’t going to work, and let me tell you why they’re not going to work: because the ACOs are going to be grouped in the large metropolitan areas and you’re going to have less competition rather than more. And so what you’re doing is you’re seeing hospitals buy physician practices, and then they’re going to get into this accountable care, and what they’re going to find is it’s not going to save them any money because you’ve got less competition.
Just go look at Boston; it’s happening right now. Prices aren’t going to go down with ACOs—they’re going to go up because you’re forcing.
What we really need is groups of physicians who say, “We’ll bid outside of the hospital; we’ll bid to make this care available.” In other words, you take 100 cardiologists and say, “Here are our rates to do these things for these people, on average.”
Let the physicians compete outside of being owned by the hospital. If you know anything about hospitals, their bureaucracy is amazing. It looks just like the federal government.
Q: What about bundling payments around episodes of care as a way to try to align incentives?
A: Well, why not let cost and outcome align incentives and let individuals do it? In other words, you’re talking about: “Here’s another system. The American consumer isn’t smart enough to buy their healthcare, so therefore, we have to have somebody else tell us how to do it.” And I would tell you, if we had no insurance in this country, none whatsoever, and we had no Medicare and people were buying their healthcare, I guarantee the prices would go down drastically, and we’d eliminate all this bureaucracy.
So what you’re suggesting is: “Here’s all these things that we can do because of the problem,” but that’s fixing the wrong problem. The problem is there’s no market force in play to control or check the cost. We’re just always looking for another gimmick. TH
Bryn Nelson is a freelance medical writer based in Seattle.
A two-time cancer survivor and obstetrician who has delivered thousands of babies, U.S. Sen. Tom Coburn (R-Okla.) has a unique perspective on healthcare as a provider, recipient, and influential advocate for change. Minutes after voting to repeal the Patient Protection and Affordable Care Act of 2010—an effort that ultimately failed in the Democratic-controlled Senate—Dr. Coburn talked with The Hospitalist about his objections to the existing law, his views on the main drivers of upwardly spiraling healthcare costs, and the Republican Party’s alternatives for achieving the elusive goals of better quality and cost control.
Question: What are your main concerns about the healthcare reform law?
Answer: I think, first of all, the healthcare reform bill doesn’t fix the problem, and the question is, what is the problem in healthcare in America? Is it quality, is it outcome, is it access, or is it cost?
And the problem is we spend twice as much per capita as anybody else in the world on healthcare to get 30% better outcomes on average. So the problem with healthcare in our country is it costs too much, and there’s a lot of reasons it costs too much. But the number-one reason is that everybody in the country, except those without insurance, thinks somebody else is paying their bill. So there’s no consumer discretionary choices that are made once you’ve met your deductible.
Having practiced for a long period of time and cared for the Amish, they always bought healthcare about 40% to 60% less than everybody else, because they pay cash for it and they deal [with] it, and they ask, “Why am I having this test?” and “Where can I get this test done more cheaply?” and “Are you sure I need this test?”
Being trained in the early 1980s and late ’70s as a physician, we’re trained different than the way doctors are trained today. Doctors today don’t think a thing about utilization. … What this bill did was expand coverage but didn’t fix the system, except that Washington’s now going to tell your hospitalists who they’re going to treat, how they’re going to treat them, and when they’re going to treat them.
Q: How do we fix the right problem?
A: You have to reconnect the purchaser with the payment; that’s No. 1. No. 2 is, you cannot continue to allow people to think somebody else is paying their bill, even when they’re not. If you work for a large company or you work for the government, the fact is, you’re paying money out every year for your portion of the coverage, and your employer is paying it out. They’re paying, in most instances, the vast majority of it, and so once you’ve met a deductible, you’re no longer a discretionary consumer because your assumption is, it’s going to get paid for.
And the other side of this is, how do we put in the doctors’ hands cost consciousness? In other words, can I do this and get the same outcome without spending this money? And quite frankly, we’ve trained a generation-and-a-half of physicians not to think about that.
Q: How else can we reduce costs?
A: It’s amazing what could happen if we start driving toward cost reduction. We have veterans who have to drive … to get to a VA. Give the veteran a card. If you’re service-connected, you can go wherever you want. Why should a veteran only be able to get access at a veterans’ healthcare center where the care isn’t as good, the outcomes aren’t as good, when they can go in their own hometown and buy something that’s better? So, you know, it’s about real freedom of choice and it’s about letting markets allocate scarce resources.
We’ve got a whole host of things that we’ve talked about on how to do this. The [Patients’ Freedom to Choose Act], it saves the states billions in terms of cost.
Q: Do you have any optimism that Congress can work together in a bipartisan way to address some of your concerns with the existing law?
A: No. This isn’t fixable in the way that they have it. To make this fixable, you have to take out the individual mandate, you have to take out the employer mandate, and you have to go to a system of risk reallocation on the insurance industry. If you want to really cover people with pre-existing illnesses, what you have to do is keep the insurance industry from cherry-picking. And what they tried to do is to get everybody covered so you could actually indemnify the whole population.
Our other problem is we’re spending money. You know, if we spent a lot of money on prevention that actually worked, we would in fact save some dollars. But we haven’t created a situation where the insurance industry is interested in keeping you as a long-term insuree, so, therefore, I don’t have any incentive to work on your wellness. Now they’re doing a little bit of that, but they’re not to a great extent. And if you knew you could buy your health insurance over a period of 20 years and be with the same company and they’d actually help teach you, get the things that are going to lower your risk and your cost, they’d both save money.
So there are all sorts of things, but what we’ve done is we’ve abandoned the thing that we use in the rest of the country to allocate scarce resources, and that’s market forces. Ask yourself why the best hospitalists in the country get paid the same as the worst. Well, why wouldn’t we want to incentivize and pay for higher quality and pay less for poorer quality and poorer outcomes, to the point where we promote excellence rather than mediocrity? But we don’t do that.
Q: What’s the next step for Republicans in trying to push forward some of your own ideas?
A: We’re going to take our [Patients’ Freedom to Choose Act] and we’re going to modify it somewhat and we’re going to introduce it and have, you know, “Here’s what we believe. You all believe this, we believe in individual freedom and personal responsibility and accountability,” and we’re going to try to do that. That won’t go anywhere because we don’t have the votes to have it go anywhere. What we’re going to wait for if the court cases. My suspicion is the president loses the court case when it gets to the Supreme Court.
Q: Do you believe the entire act will be struck down or just the individual mandate?
A: No, no. I think the entire act will be struck. The bill doesn’t work without the individual mandate because you don’t get enough revenues in to cover what—and the bill is scored so stupidly anyhow. I don’t know if you know much about government budgeting, but this thing’s a farce in terms of its cost. It’s going to cost fully $600 billion to a trillion dollars more in the first year [2014] than they’re saying it will.
Q: What’s your view on accountable-care organizations?
A: Accountable-care organizations (ACOs) aren’t going to work, and let me tell you why they’re not going to work: because the ACOs are going to be grouped in the large metropolitan areas and you’re going to have less competition rather than more. And so what you’re doing is you’re seeing hospitals buy physician practices, and then they’re going to get into this accountable care, and what they’re going to find is it’s not going to save them any money because you’ve got less competition.
Just go look at Boston; it’s happening right now. Prices aren’t going to go down with ACOs—they’re going to go up because you’re forcing.
What we really need is groups of physicians who say, “We’ll bid outside of the hospital; we’ll bid to make this care available.” In other words, you take 100 cardiologists and say, “Here are our rates to do these things for these people, on average.”
Let the physicians compete outside of being owned by the hospital. If you know anything about hospitals, their bureaucracy is amazing. It looks just like the federal government.
Q: What about bundling payments around episodes of care as a way to try to align incentives?
A: Well, why not let cost and outcome align incentives and let individuals do it? In other words, you’re talking about: “Here’s another system. The American consumer isn’t smart enough to buy their healthcare, so therefore, we have to have somebody else tell us how to do it.” And I would tell you, if we had no insurance in this country, none whatsoever, and we had no Medicare and people were buying their healthcare, I guarantee the prices would go down drastically, and we’d eliminate all this bureaucracy.
So what you’re suggesting is: “Here’s all these things that we can do because of the problem,” but that’s fixing the wrong problem. The problem is there’s no market force in play to control or check the cost. We’re just always looking for another gimmick. TH
Bryn Nelson is a freelance medical writer based in Seattle.
A two-time cancer survivor and obstetrician who has delivered thousands of babies, U.S. Sen. Tom Coburn (R-Okla.) has a unique perspective on healthcare as a provider, recipient, and influential advocate for change. Minutes after voting to repeal the Patient Protection and Affordable Care Act of 2010—an effort that ultimately failed in the Democratic-controlled Senate—Dr. Coburn talked with The Hospitalist about his objections to the existing law, his views on the main drivers of upwardly spiraling healthcare costs, and the Republican Party’s alternatives for achieving the elusive goals of better quality and cost control.
Question: What are your main concerns about the healthcare reform law?
Answer: I think, first of all, the healthcare reform bill doesn’t fix the problem, and the question is, what is the problem in healthcare in America? Is it quality, is it outcome, is it access, or is it cost?
And the problem is we spend twice as much per capita as anybody else in the world on healthcare to get 30% better outcomes on average. So the problem with healthcare in our country is it costs too much, and there’s a lot of reasons it costs too much. But the number-one reason is that everybody in the country, except those without insurance, thinks somebody else is paying their bill. So there’s no consumer discretionary choices that are made once you’ve met your deductible.
Having practiced for a long period of time and cared for the Amish, they always bought healthcare about 40% to 60% less than everybody else, because they pay cash for it and they deal [with] it, and they ask, “Why am I having this test?” and “Where can I get this test done more cheaply?” and “Are you sure I need this test?”
Being trained in the early 1980s and late ’70s as a physician, we’re trained different than the way doctors are trained today. Doctors today don’t think a thing about utilization. … What this bill did was expand coverage but didn’t fix the system, except that Washington’s now going to tell your hospitalists who they’re going to treat, how they’re going to treat them, and when they’re going to treat them.
Q: How do we fix the right problem?
A: You have to reconnect the purchaser with the payment; that’s No. 1. No. 2 is, you cannot continue to allow people to think somebody else is paying their bill, even when they’re not. If you work for a large company or you work for the government, the fact is, you’re paying money out every year for your portion of the coverage, and your employer is paying it out. They’re paying, in most instances, the vast majority of it, and so once you’ve met a deductible, you’re no longer a discretionary consumer because your assumption is, it’s going to get paid for.
And the other side of this is, how do we put in the doctors’ hands cost consciousness? In other words, can I do this and get the same outcome without spending this money? And quite frankly, we’ve trained a generation-and-a-half of physicians not to think about that.
Q: How else can we reduce costs?
A: It’s amazing what could happen if we start driving toward cost reduction. We have veterans who have to drive … to get to a VA. Give the veteran a card. If you’re service-connected, you can go wherever you want. Why should a veteran only be able to get access at a veterans’ healthcare center where the care isn’t as good, the outcomes aren’t as good, when they can go in their own hometown and buy something that’s better? So, you know, it’s about real freedom of choice and it’s about letting markets allocate scarce resources.
We’ve got a whole host of things that we’ve talked about on how to do this. The [Patients’ Freedom to Choose Act], it saves the states billions in terms of cost.
Q: Do you have any optimism that Congress can work together in a bipartisan way to address some of your concerns with the existing law?
A: No. This isn’t fixable in the way that they have it. To make this fixable, you have to take out the individual mandate, you have to take out the employer mandate, and you have to go to a system of risk reallocation on the insurance industry. If you want to really cover people with pre-existing illnesses, what you have to do is keep the insurance industry from cherry-picking. And what they tried to do is to get everybody covered so you could actually indemnify the whole population.
Our other problem is we’re spending money. You know, if we spent a lot of money on prevention that actually worked, we would in fact save some dollars. But we haven’t created a situation where the insurance industry is interested in keeping you as a long-term insuree, so, therefore, I don’t have any incentive to work on your wellness. Now they’re doing a little bit of that, but they’re not to a great extent. And if you knew you could buy your health insurance over a period of 20 years and be with the same company and they’d actually help teach you, get the things that are going to lower your risk and your cost, they’d both save money.
So there are all sorts of things, but what we’ve done is we’ve abandoned the thing that we use in the rest of the country to allocate scarce resources, and that’s market forces. Ask yourself why the best hospitalists in the country get paid the same as the worst. Well, why wouldn’t we want to incentivize and pay for higher quality and pay less for poorer quality and poorer outcomes, to the point where we promote excellence rather than mediocrity? But we don’t do that.
Q: What’s the next step for Republicans in trying to push forward some of your own ideas?
A: We’re going to take our [Patients’ Freedom to Choose Act] and we’re going to modify it somewhat and we’re going to introduce it and have, you know, “Here’s what we believe. You all believe this, we believe in individual freedom and personal responsibility and accountability,” and we’re going to try to do that. That won’t go anywhere because we don’t have the votes to have it go anywhere. What we’re going to wait for if the court cases. My suspicion is the president loses the court case when it gets to the Supreme Court.
Q: Do you believe the entire act will be struck down or just the individual mandate?
A: No, no. I think the entire act will be struck. The bill doesn’t work without the individual mandate because you don’t get enough revenues in to cover what—and the bill is scored so stupidly anyhow. I don’t know if you know much about government budgeting, but this thing’s a farce in terms of its cost. It’s going to cost fully $600 billion to a trillion dollars more in the first year [2014] than they’re saying it will.
Q: What’s your view on accountable-care organizations?
A: Accountable-care organizations (ACOs) aren’t going to work, and let me tell you why they’re not going to work: because the ACOs are going to be grouped in the large metropolitan areas and you’re going to have less competition rather than more. And so what you’re doing is you’re seeing hospitals buy physician practices, and then they’re going to get into this accountable care, and what they’re going to find is it’s not going to save them any money because you’ve got less competition.
Just go look at Boston; it’s happening right now. Prices aren’t going to go down with ACOs—they’re going to go up because you’re forcing.
What we really need is groups of physicians who say, “We’ll bid outside of the hospital; we’ll bid to make this care available.” In other words, you take 100 cardiologists and say, “Here are our rates to do these things for these people, on average.”
Let the physicians compete outside of being owned by the hospital. If you know anything about hospitals, their bureaucracy is amazing. It looks just like the federal government.
Q: What about bundling payments around episodes of care as a way to try to align incentives?
A: Well, why not let cost and outcome align incentives and let individuals do it? In other words, you’re talking about: “Here’s another system. The American consumer isn’t smart enough to buy their healthcare, so therefore, we have to have somebody else tell us how to do it.” And I would tell you, if we had no insurance in this country, none whatsoever, and we had no Medicare and people were buying their healthcare, I guarantee the prices would go down drastically, and we’d eliminate all this bureaucracy.
So what you’re suggesting is: “Here’s all these things that we can do because of the problem,” but that’s fixing the wrong problem. The problem is there’s no market force in play to control or check the cost. We’re just always looking for another gimmick. TH
Bryn Nelson is a freelance medical writer based in Seattle.
Health Reform Turns 1
As America’s love-hate relationship with healthcare reform approaches its first anniversary, the law is proving just as divisive now as it was during the midterm elections. Fittingly, the Patient Protection and Affordable Care Act of 2010 (ACA), which has polarized the country, is moving forward along three separate tracks.
“Usually, at this point of the game one would only be worrying about the implementation,” says Leighton Ku, a health-policy analyst at George Washington University. “But, obviously, there’s been enough discord that the political route and the legal route are now equally important.”
Here’s a look at where the ACA stands from practical, political, and legal standpoints, along with the major players involved in the ongoing tussle.
The Battle of Public Perception
America is hopelessly divided. Despite pollsters’ best efforts to break the stalemate, the collective numbers still suggest that roughly equal numbers of respondents favor and oppose healthcare reform (with a slight advantage to opponents). It’s a trend line that has barely budged since the bill’s enactment last March.
In January, the Republican-led House of Representatives voted to repeal the entire reform act in what analysts have called a largely symbolic gesture, given that the repeal effort subsequently failed in the Democratic-controlled Senate. Even so, Ku says, the vote fulfills a Republican campaign promise and sends a strong signal to the party’s political base. “What’s driving the Republicans is that their constituencies really don’t like it,” agrees Robert J. Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. “Almost all Republican congressmen who ran had on their website, ‘I will repeal this bill if elected.’ ”
But opposition doesn’t necessarily mean voters want everything repealed, a caveat also borne out by recent polling. “Where the public stands is a little more ambiguous than what the campaign rhetoric is,” Ku says. That ambiguity could present an opportunity for both parties to reframe the debate in the coming months in an effort to win over a clear majority of the public. With the economy of paramount concern, Republicans have cast healthcare reform as a “job-destroying” act that will speed the country’s descent into bankruptcy.
If the economy improves, however, opposition to the law is likely to soften. And with their “no” vote behind them, Republicans in the House will be expected to craft a coherent alternative to the legislation. “Now comes the tough part,” Ku says.
Democrats, meanwhile, have largely regrouped and are being more vocal about the law’s necessity—after a campaign season in which many conservative Democrats largely avoided talking about it, or even touted their opposition to it, and were beaten anyway.
In the absence of wholesale repeal, a few individual provisions might be stripped away. Most key elements cannot be defunded, although Republicans could cut funding streams to Health and Human Services (HHS) or the IRS to hamper implementation. Congress also could choose not to appropriate money to the estimated $106 billion worth of new spending authorizations. A sizable percentage of that pool covers popular pre-existing programs, however, which makes a “no” vote politically more risky.
A Matter of Time
The nonpartisan Congressional Budget Office has predicted that repealing the healthcare reform legislation would increase the federal deficit by $230 billion over the next decade. Even so, the law’s supporters are finding little traction among voters who have heard repeated claims by Republicans that the act itself will push the country deeper into debt (many Republicans say the CBO estimate is based on faulty numbers provided by the law’s supporters). One big reason why: The tanking economy has eroded public trust in the government. “The ratings of trust in the federal government are so low,” Blendon says, “you need a stethoscope to try to hear them.”
And then there’s the matter of time. Because the act’s biggest provisions don’t go into effect until 2014, there are no made-for-media moments—like the large numbers of previously uninsured receiving health insurance cards—to counter the dire predictions that patients will lose their doctors. Instead, the White House has tried to make the most of smaller provisions now in effect, such as one that allows children to stay on a parent’s insurance until their 26th birthday, another that lifts the lifetime caps on insurance coverage, and a third that bans insurers from dropping children with pre-existing conditions (a video explaining what the ACA does and doesn’t do, produced by the Kaiser Family Foundation, is available at http://healthreform.kff.org/The Animation.aspx).
In mid-January, on the eve of the House vote to repeal the entire act, the White House released an HHS study to bolster its contention that the law will eventually aid tens of millions, and, conversely, that any repeal would harm them (www.healthcare.gov/center/reports/preexisting.html). The study estimates that 50 million to 129 million Americans under the age of 65 have pre-existing conditions that would, theoretically, make it harder for them to buy insurance in the absence of regulations requiring coverage. But the study also reports that up to 82 million of these people already have employer-provided insurance, meaning they wouldn’t be affected either way unless they switch jobs or become unemployed.
The White House’s case has been made harder by the confluence of a poor economy, growing concern over the deficit, and the ongoing battle over whether and how to fix the Medicare reimbursement rate paid to doctors, according to Blendon. When the rate paid to doctors temporarily nosedived last June, stories about doctors refusing to see Medicare beneficiaries proliferated among alarmed seniors (Congress eventually passed another short-term patch). The memory of that lack of medical access is now being conflated with the potential side effects of the new law by the constituency most likely to vote (seniors) and most skeptical in general about healthcare reform.
Legal Limbo
More than half the states have now joined lawsuits challenging the ACA’s constitutionality. In the first of what observers expect to be a multitude of legal decisions, federal judges in two cases upheld the law, and the individual mandate requiring people to buy health insurance was ruled unconstitutional in a third.
Ultimately, most experts believe the Supreme Court will have the final say, likely before the 2012 elections. Ku says analysts already are talking about a possible 5-4 decision, with Justice Anthony Kennedy as the potential swing vote—though so far, he’s given no clear hints about which way he may be leaning. Even if the individual mandate component is struck down, Ku says, the court could uphold everything else, changing its overall impact but not the implementation of most provisions. TH
Bryn Nelson is a freelance medical writer based in Seattle.
Key Players in the Healthcare Debate
John Boehner (R-Ohio), the new Speaker of the House, is the public face of many Republican talking points on healthcare reform and the leader in trying to maintain a unified front against the existing law.
Paul Ryan (R-Wis.), chairman of the House Budget Committee and a senior member of the Ways and Means Committee, delivered the GOP response to President Obama’s State of the Union address. He will help the party craft a coherent ACA alternative.
Many conservative “Blue Dog” Democrats either actively opposed the law or stayed silent about it—and got routed in November anyway. Most remaining Blue Dogs have since rejoined the party in highlighting the ACA’s benefits. If Republicans pass an alternative measure, it would need to attract some Democratic support to be seen as bipartisan.
Although Sen. Majority Leader Harry Reid (D-Nev.) is opposing any attempt to bring up a vote on repealing the law, Minority Leader Mitch McConnell (R-Ky.) has kept the pressure on, vowing to find a way to force a vote on repealing what he told Fox News Sunday was “the single worst piece of legislation passed in my time in the Senate.” Obama was criticized by other Democrats for not being more vocal about healthcare reform’s benefits in the leadup to the November elections. The repeal effort gives him another chance to make his case.
HHS Secretary Kathleen Sebelius likely will testify repeatedly in hearings called by the Republican leadership to scrutinize how the law is being implemented.
Supreme Court Justice Anthony Kennedy, appointed by President Reagan, is expected to be the swing vote in a closely divided court. The issue: whether an individual mandate requiring people to buy insurance is constitutional. So far, he has given little indication as to how he might rule.
—BN
As America’s love-hate relationship with healthcare reform approaches its first anniversary, the law is proving just as divisive now as it was during the midterm elections. Fittingly, the Patient Protection and Affordable Care Act of 2010 (ACA), which has polarized the country, is moving forward along three separate tracks.
“Usually, at this point of the game one would only be worrying about the implementation,” says Leighton Ku, a health-policy analyst at George Washington University. “But, obviously, there’s been enough discord that the political route and the legal route are now equally important.”
Here’s a look at where the ACA stands from practical, political, and legal standpoints, along with the major players involved in the ongoing tussle.
The Battle of Public Perception
America is hopelessly divided. Despite pollsters’ best efforts to break the stalemate, the collective numbers still suggest that roughly equal numbers of respondents favor and oppose healthcare reform (with a slight advantage to opponents). It’s a trend line that has barely budged since the bill’s enactment last March.
In January, the Republican-led House of Representatives voted to repeal the entire reform act in what analysts have called a largely symbolic gesture, given that the repeal effort subsequently failed in the Democratic-controlled Senate. Even so, Ku says, the vote fulfills a Republican campaign promise and sends a strong signal to the party’s political base. “What’s driving the Republicans is that their constituencies really don’t like it,” agrees Robert J. Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. “Almost all Republican congressmen who ran had on their website, ‘I will repeal this bill if elected.’ ”
But opposition doesn’t necessarily mean voters want everything repealed, a caveat also borne out by recent polling. “Where the public stands is a little more ambiguous than what the campaign rhetoric is,” Ku says. That ambiguity could present an opportunity for both parties to reframe the debate in the coming months in an effort to win over a clear majority of the public. With the economy of paramount concern, Republicans have cast healthcare reform as a “job-destroying” act that will speed the country’s descent into bankruptcy.
If the economy improves, however, opposition to the law is likely to soften. And with their “no” vote behind them, Republicans in the House will be expected to craft a coherent alternative to the legislation. “Now comes the tough part,” Ku says.
Democrats, meanwhile, have largely regrouped and are being more vocal about the law’s necessity—after a campaign season in which many conservative Democrats largely avoided talking about it, or even touted their opposition to it, and were beaten anyway.
In the absence of wholesale repeal, a few individual provisions might be stripped away. Most key elements cannot be defunded, although Republicans could cut funding streams to Health and Human Services (HHS) or the IRS to hamper implementation. Congress also could choose not to appropriate money to the estimated $106 billion worth of new spending authorizations. A sizable percentage of that pool covers popular pre-existing programs, however, which makes a “no” vote politically more risky.
A Matter of Time
The nonpartisan Congressional Budget Office has predicted that repealing the healthcare reform legislation would increase the federal deficit by $230 billion over the next decade. Even so, the law’s supporters are finding little traction among voters who have heard repeated claims by Republicans that the act itself will push the country deeper into debt (many Republicans say the CBO estimate is based on faulty numbers provided by the law’s supporters). One big reason why: The tanking economy has eroded public trust in the government. “The ratings of trust in the federal government are so low,” Blendon says, “you need a stethoscope to try to hear them.”
And then there’s the matter of time. Because the act’s biggest provisions don’t go into effect until 2014, there are no made-for-media moments—like the large numbers of previously uninsured receiving health insurance cards—to counter the dire predictions that patients will lose their doctors. Instead, the White House has tried to make the most of smaller provisions now in effect, such as one that allows children to stay on a parent’s insurance until their 26th birthday, another that lifts the lifetime caps on insurance coverage, and a third that bans insurers from dropping children with pre-existing conditions (a video explaining what the ACA does and doesn’t do, produced by the Kaiser Family Foundation, is available at http://healthreform.kff.org/The Animation.aspx).
In mid-January, on the eve of the House vote to repeal the entire act, the White House released an HHS study to bolster its contention that the law will eventually aid tens of millions, and, conversely, that any repeal would harm them (www.healthcare.gov/center/reports/preexisting.html). The study estimates that 50 million to 129 million Americans under the age of 65 have pre-existing conditions that would, theoretically, make it harder for them to buy insurance in the absence of regulations requiring coverage. But the study also reports that up to 82 million of these people already have employer-provided insurance, meaning they wouldn’t be affected either way unless they switch jobs or become unemployed.
The White House’s case has been made harder by the confluence of a poor economy, growing concern over the deficit, and the ongoing battle over whether and how to fix the Medicare reimbursement rate paid to doctors, according to Blendon. When the rate paid to doctors temporarily nosedived last June, stories about doctors refusing to see Medicare beneficiaries proliferated among alarmed seniors (Congress eventually passed another short-term patch). The memory of that lack of medical access is now being conflated with the potential side effects of the new law by the constituency most likely to vote (seniors) and most skeptical in general about healthcare reform.
Legal Limbo
More than half the states have now joined lawsuits challenging the ACA’s constitutionality. In the first of what observers expect to be a multitude of legal decisions, federal judges in two cases upheld the law, and the individual mandate requiring people to buy health insurance was ruled unconstitutional in a third.
Ultimately, most experts believe the Supreme Court will have the final say, likely before the 2012 elections. Ku says analysts already are talking about a possible 5-4 decision, with Justice Anthony Kennedy as the potential swing vote—though so far, he’s given no clear hints about which way he may be leaning. Even if the individual mandate component is struck down, Ku says, the court could uphold everything else, changing its overall impact but not the implementation of most provisions. TH
Bryn Nelson is a freelance medical writer based in Seattle.
Key Players in the Healthcare Debate
John Boehner (R-Ohio), the new Speaker of the House, is the public face of many Republican talking points on healthcare reform and the leader in trying to maintain a unified front against the existing law.
Paul Ryan (R-Wis.), chairman of the House Budget Committee and a senior member of the Ways and Means Committee, delivered the GOP response to President Obama’s State of the Union address. He will help the party craft a coherent ACA alternative.
Many conservative “Blue Dog” Democrats either actively opposed the law or stayed silent about it—and got routed in November anyway. Most remaining Blue Dogs have since rejoined the party in highlighting the ACA’s benefits. If Republicans pass an alternative measure, it would need to attract some Democratic support to be seen as bipartisan.
Although Sen. Majority Leader Harry Reid (D-Nev.) is opposing any attempt to bring up a vote on repealing the law, Minority Leader Mitch McConnell (R-Ky.) has kept the pressure on, vowing to find a way to force a vote on repealing what he told Fox News Sunday was “the single worst piece of legislation passed in my time in the Senate.” Obama was criticized by other Democrats for not being more vocal about healthcare reform’s benefits in the leadup to the November elections. The repeal effort gives him another chance to make his case.
HHS Secretary Kathleen Sebelius likely will testify repeatedly in hearings called by the Republican leadership to scrutinize how the law is being implemented.
Supreme Court Justice Anthony Kennedy, appointed by President Reagan, is expected to be the swing vote in a closely divided court. The issue: whether an individual mandate requiring people to buy insurance is constitutional. So far, he has given little indication as to how he might rule.
—BN
As America’s love-hate relationship with healthcare reform approaches its first anniversary, the law is proving just as divisive now as it was during the midterm elections. Fittingly, the Patient Protection and Affordable Care Act of 2010 (ACA), which has polarized the country, is moving forward along three separate tracks.
“Usually, at this point of the game one would only be worrying about the implementation,” says Leighton Ku, a health-policy analyst at George Washington University. “But, obviously, there’s been enough discord that the political route and the legal route are now equally important.”
Here’s a look at where the ACA stands from practical, political, and legal standpoints, along with the major players involved in the ongoing tussle.
The Battle of Public Perception
America is hopelessly divided. Despite pollsters’ best efforts to break the stalemate, the collective numbers still suggest that roughly equal numbers of respondents favor and oppose healthcare reform (with a slight advantage to opponents). It’s a trend line that has barely budged since the bill’s enactment last March.
In January, the Republican-led House of Representatives voted to repeal the entire reform act in what analysts have called a largely symbolic gesture, given that the repeal effort subsequently failed in the Democratic-controlled Senate. Even so, Ku says, the vote fulfills a Republican campaign promise and sends a strong signal to the party’s political base. “What’s driving the Republicans is that their constituencies really don’t like it,” agrees Robert J. Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. “Almost all Republican congressmen who ran had on their website, ‘I will repeal this bill if elected.’ ”
But opposition doesn’t necessarily mean voters want everything repealed, a caveat also borne out by recent polling. “Where the public stands is a little more ambiguous than what the campaign rhetoric is,” Ku says. That ambiguity could present an opportunity for both parties to reframe the debate in the coming months in an effort to win over a clear majority of the public. With the economy of paramount concern, Republicans have cast healthcare reform as a “job-destroying” act that will speed the country’s descent into bankruptcy.
If the economy improves, however, opposition to the law is likely to soften. And with their “no” vote behind them, Republicans in the House will be expected to craft a coherent alternative to the legislation. “Now comes the tough part,” Ku says.
Democrats, meanwhile, have largely regrouped and are being more vocal about the law’s necessity—after a campaign season in which many conservative Democrats largely avoided talking about it, or even touted their opposition to it, and were beaten anyway.
In the absence of wholesale repeal, a few individual provisions might be stripped away. Most key elements cannot be defunded, although Republicans could cut funding streams to Health and Human Services (HHS) or the IRS to hamper implementation. Congress also could choose not to appropriate money to the estimated $106 billion worth of new spending authorizations. A sizable percentage of that pool covers popular pre-existing programs, however, which makes a “no” vote politically more risky.
A Matter of Time
The nonpartisan Congressional Budget Office has predicted that repealing the healthcare reform legislation would increase the federal deficit by $230 billion over the next decade. Even so, the law’s supporters are finding little traction among voters who have heard repeated claims by Republicans that the act itself will push the country deeper into debt (many Republicans say the CBO estimate is based on faulty numbers provided by the law’s supporters). One big reason why: The tanking economy has eroded public trust in the government. “The ratings of trust in the federal government are so low,” Blendon says, “you need a stethoscope to try to hear them.”
And then there’s the matter of time. Because the act’s biggest provisions don’t go into effect until 2014, there are no made-for-media moments—like the large numbers of previously uninsured receiving health insurance cards—to counter the dire predictions that patients will lose their doctors. Instead, the White House has tried to make the most of smaller provisions now in effect, such as one that allows children to stay on a parent’s insurance until their 26th birthday, another that lifts the lifetime caps on insurance coverage, and a third that bans insurers from dropping children with pre-existing conditions (a video explaining what the ACA does and doesn’t do, produced by the Kaiser Family Foundation, is available at http://healthreform.kff.org/The Animation.aspx).
In mid-January, on the eve of the House vote to repeal the entire act, the White House released an HHS study to bolster its contention that the law will eventually aid tens of millions, and, conversely, that any repeal would harm them (www.healthcare.gov/center/reports/preexisting.html). The study estimates that 50 million to 129 million Americans under the age of 65 have pre-existing conditions that would, theoretically, make it harder for them to buy insurance in the absence of regulations requiring coverage. But the study also reports that up to 82 million of these people already have employer-provided insurance, meaning they wouldn’t be affected either way unless they switch jobs or become unemployed.
The White House’s case has been made harder by the confluence of a poor economy, growing concern over the deficit, and the ongoing battle over whether and how to fix the Medicare reimbursement rate paid to doctors, according to Blendon. When the rate paid to doctors temporarily nosedived last June, stories about doctors refusing to see Medicare beneficiaries proliferated among alarmed seniors (Congress eventually passed another short-term patch). The memory of that lack of medical access is now being conflated with the potential side effects of the new law by the constituency most likely to vote (seniors) and most skeptical in general about healthcare reform.
Legal Limbo
More than half the states have now joined lawsuits challenging the ACA’s constitutionality. In the first of what observers expect to be a multitude of legal decisions, federal judges in two cases upheld the law, and the individual mandate requiring people to buy health insurance was ruled unconstitutional in a third.
Ultimately, most experts believe the Supreme Court will have the final say, likely before the 2012 elections. Ku says analysts already are talking about a possible 5-4 decision, with Justice Anthony Kennedy as the potential swing vote—though so far, he’s given no clear hints about which way he may be leaning. Even if the individual mandate component is struck down, Ku says, the court could uphold everything else, changing its overall impact but not the implementation of most provisions. TH
Bryn Nelson is a freelance medical writer based in Seattle.
Key Players in the Healthcare Debate
John Boehner (R-Ohio), the new Speaker of the House, is the public face of many Republican talking points on healthcare reform and the leader in trying to maintain a unified front against the existing law.
Paul Ryan (R-Wis.), chairman of the House Budget Committee and a senior member of the Ways and Means Committee, delivered the GOP response to President Obama’s State of the Union address. He will help the party craft a coherent ACA alternative.
Many conservative “Blue Dog” Democrats either actively opposed the law or stayed silent about it—and got routed in November anyway. Most remaining Blue Dogs have since rejoined the party in highlighting the ACA’s benefits. If Republicans pass an alternative measure, it would need to attract some Democratic support to be seen as bipartisan.
Although Sen. Majority Leader Harry Reid (D-Nev.) is opposing any attempt to bring up a vote on repealing the law, Minority Leader Mitch McConnell (R-Ky.) has kept the pressure on, vowing to find a way to force a vote on repealing what he told Fox News Sunday was “the single worst piece of legislation passed in my time in the Senate.” Obama was criticized by other Democrats for not being more vocal about healthcare reform’s benefits in the leadup to the November elections. The repeal effort gives him another chance to make his case.
HHS Secretary Kathleen Sebelius likely will testify repeatedly in hearings called by the Republican leadership to scrutinize how the law is being implemented.
Supreme Court Justice Anthony Kennedy, appointed by President Reagan, is expected to be the swing vote in a closely divided court. The issue: whether an individual mandate requiring people to buy insurance is constitutional. So far, he has given little indication as to how he might rule.
—BN
Minivan, Major Lesson
I recently visited my parents in my ancestral home of Wisconsin. As parents of a certain age, they inexplicably are genetically predisposed to owning a minivan. Another quirk of their DNA is that they must own a new minivan. No sooner has the last wisp of new-car smell osmosed from the burled walnut interior than they are trading up to the newest, tricked-out minivan. Perhaps more puzzling is the manner of pride they display in their minivan.
Now, my dad, as if not readily apparent, is not cool. And to see him folded into the driver’s seat, his furry-ear-to-furry-ear grin signaling a self-satisfaction customarily reserved for his grandchildren, painstakingly recounting glory-day stories and 4:30 p.m. dinner buffets, further solidifies his place in the Annals of Uncool.
When I’m home, they tend to employ my chauffeur services (most likely in retribution for my peri-pubescent years), and on the first day back home, I stopped their newest ride near the back door of the house, foot idling on the brake while this exchange occurred: “That’s a fascinating story about how much more challenging the world was when you were my age, Dad. You are a true American hero. Would you like to get out here or in the garage?”
“Here,” he replied.
“OK, then get out,” I countered.
“I can’t,” he responded knowingly.
“Why not?” I queried, the patience seeping from my voice.
“Because the door’s not open,” he answered, seemingly mocking me.
“Then open it,” I replied, silently recounting the evidence for his institutionalization.
“I can’t,” he responded.
“Why not?” I replied again, this time calculating the likelihood that I was adopted.
“Because it’s locked,” came his retort.
“Then unlock it,” I answered, reconfirming my decision to move away for college.
“I can’t,” he replied, ostensibly encouraging parenticide.
“Why not?” I queried, strongly contemplating parenticide.
“Because you haven’t put the car in park,” he responded triumphantly.
A System So Safe
As a safety feature, the minivan needed to be in park before you could open the door to exit. I’ve never heard of anyone actually falling out of a moving car, but recollecting high school, I can fathom the right mix, type, and number of teenagers where possibility would meet inevitability. But, apparently, enough people are falling out of moving vehicles that car engineers have built a system that is so safe, this can’t happen. So no matter how hard someone tries, it just isn’t possible to fall out of a moving car (believe me, toward the end of a week of my father’s car stories, my mind had worked every possible angle).
Likewise, newer vehicles employ occupant-sensitive sensors that detect the weight, size, and position of the passenger to determine if the airbag should deploy. Rather than depending on the driver to turn the passenger-side airbag on or off, the car does it for you: heavy enough to trigger the sensor, and the airbag will deploy; too light, and the car assumes you are a child and doesn’t deploy. It’s a system that is so safe because it doesn’t depend on the operator to get it right.
Ditto motion sensors that detect objects behind the car while reversing (avoiding accidental back-overs), antilock brakes (to maintain control during panicked braking), traction control (improves stability during acceleration), electronic stability control (foils spinouts), tire-pressure-monitoring systems (avoids blowouts), daytime running lights (ensures others see you), rollover airbags (they stay inflated to keep you in the car), lane-departure warning (alerts you if you stray from your lane), and doors that automatically lock after the car starts (again, falling out of cars).
For all the negative press of late, car manufacturers understand safety.
A System Not So Safe
Contrast this to healthcare, in which 10% of patients will suffer a serious, preventable, adverse event during their hospital stay.1 Read that sentence again. That’s 10%; that’s preventable; that’s a number that has largely remained unchanged in the past decade. If 1 in 10 drivers suffered a serious adverse preventable auto accident, Congress would do nothing but hold automotive safety hearings.
In medicine, we still largely employ unsafe systems in which even the best doctors can, and do, hurt patients. Sure, we have made strides in this arena (oxygen tubing that only works if hooked up properly, smart pumps that avert IV dosing errors, CO2 monitors to detect proper endotracheal tube placement), but remarkably, in this era of patient safety, we still utilize systems that largely depend on the heroism of the individual.
As physicians, we are famously autonomous and value our professional independence, even to the degree that it might harm patients. We generally eschew standardization, believing that each patient is inherently different. In fact, the thrill of the improvisational theater that follows every patient’s chief compliant is one of the great satisfiers in medicine. We love that feeling that comes from sleuthing each case, deftly enacting a plan of action to shepherd the patient to health.
To suggest following protocols, guidelines, and checklists is derisively dismissed as “cookbook medicine.” To work in teams in which certain tasks are delegated to others is seen as weakness—we don’t need a system that utilizes a pharmacist; rather, we should know the doses of all medicines, their interactions, and the effect of renal and liver impairment on their clearance. To suggest otherwise is an insult to our Oslerian roots. To examine our errors, our system breakdowns, our patient harms is anathema to our practice, an admission of failure.
The result is that most of us continue to toil in systems that have become exponentially unsafe as healthcare has become more complex. Today, we still have a system that will more or less allow us to kill a patient by doing nothing more than forgetting the letter “g.” I can go to my hospital today and intend to write “4 grams of magnesium sulfate (MgSO4)” and inadvertently forget the “g” in “Mg.” This could result in an order for a lethal dose of morphine sulfate (MSO4). It’s that easy to hurt a patient. Now, you might say that would never happen, because the pharmacy would catch it. And this is likely. But is it guaranteed? Can you 100% ensure it wouldn’t happen? Consider that nearly 20% of medication doses administered in a hospital are done so incorrectly.2 Nearly 1 in 5. This is the type of system we are employing to stop this lethal overdose. Is this system, which depends on another human to prevent an error, foolproof, or just a snare waiting to prove you the fool?
This represents our opportunity. As hospitalists, the hospital is our tapestry, our system of care, our responsibility. Few others are as well-positioned to ensure that the systems that envelop our patients are highly functional, reliable, and safe. This will take work—work that will feel burdensome, underappreciated, undercompensated. And, fully recognizing that none of us went into medicine to become systems engineers, this will be hard.
However, if not us, who? Who will ensure that our fathers, our mothers, our children will be as safe in the hospital as they are on the drive to the hospital? TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
References
- Global health leaders join the World Health Organization to announce accelerated efforts to improve patient safety. World Health Organization website. Available at: www.who.int/mediacentre/news/releases/2004/pr74/en/. Accessed Feb. 14, 2011.
- Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162(16):1897-1903.
I recently visited my parents in my ancestral home of Wisconsin. As parents of a certain age, they inexplicably are genetically predisposed to owning a minivan. Another quirk of their DNA is that they must own a new minivan. No sooner has the last wisp of new-car smell osmosed from the burled walnut interior than they are trading up to the newest, tricked-out minivan. Perhaps more puzzling is the manner of pride they display in their minivan.
Now, my dad, as if not readily apparent, is not cool. And to see him folded into the driver’s seat, his furry-ear-to-furry-ear grin signaling a self-satisfaction customarily reserved for his grandchildren, painstakingly recounting glory-day stories and 4:30 p.m. dinner buffets, further solidifies his place in the Annals of Uncool.
When I’m home, they tend to employ my chauffeur services (most likely in retribution for my peri-pubescent years), and on the first day back home, I stopped their newest ride near the back door of the house, foot idling on the brake while this exchange occurred: “That’s a fascinating story about how much more challenging the world was when you were my age, Dad. You are a true American hero. Would you like to get out here or in the garage?”
“Here,” he replied.
“OK, then get out,” I countered.
“I can’t,” he responded knowingly.
“Why not?” I queried, the patience seeping from my voice.
“Because the door’s not open,” he answered, seemingly mocking me.
“Then open it,” I replied, silently recounting the evidence for his institutionalization.
“I can’t,” he responded.
“Why not?” I replied again, this time calculating the likelihood that I was adopted.
“Because it’s locked,” came his retort.
“Then unlock it,” I answered, reconfirming my decision to move away for college.
“I can’t,” he replied, ostensibly encouraging parenticide.
“Why not?” I queried, strongly contemplating parenticide.
“Because you haven’t put the car in park,” he responded triumphantly.
A System So Safe
As a safety feature, the minivan needed to be in park before you could open the door to exit. I’ve never heard of anyone actually falling out of a moving car, but recollecting high school, I can fathom the right mix, type, and number of teenagers where possibility would meet inevitability. But, apparently, enough people are falling out of moving vehicles that car engineers have built a system that is so safe, this can’t happen. So no matter how hard someone tries, it just isn’t possible to fall out of a moving car (believe me, toward the end of a week of my father’s car stories, my mind had worked every possible angle).
Likewise, newer vehicles employ occupant-sensitive sensors that detect the weight, size, and position of the passenger to determine if the airbag should deploy. Rather than depending on the driver to turn the passenger-side airbag on or off, the car does it for you: heavy enough to trigger the sensor, and the airbag will deploy; too light, and the car assumes you are a child and doesn’t deploy. It’s a system that is so safe because it doesn’t depend on the operator to get it right.
Ditto motion sensors that detect objects behind the car while reversing (avoiding accidental back-overs), antilock brakes (to maintain control during panicked braking), traction control (improves stability during acceleration), electronic stability control (foils spinouts), tire-pressure-monitoring systems (avoids blowouts), daytime running lights (ensures others see you), rollover airbags (they stay inflated to keep you in the car), lane-departure warning (alerts you if you stray from your lane), and doors that automatically lock after the car starts (again, falling out of cars).
For all the negative press of late, car manufacturers understand safety.
A System Not So Safe
Contrast this to healthcare, in which 10% of patients will suffer a serious, preventable, adverse event during their hospital stay.1 Read that sentence again. That’s 10%; that’s preventable; that’s a number that has largely remained unchanged in the past decade. If 1 in 10 drivers suffered a serious adverse preventable auto accident, Congress would do nothing but hold automotive safety hearings.
In medicine, we still largely employ unsafe systems in which even the best doctors can, and do, hurt patients. Sure, we have made strides in this arena (oxygen tubing that only works if hooked up properly, smart pumps that avert IV dosing errors, CO2 monitors to detect proper endotracheal tube placement), but remarkably, in this era of patient safety, we still utilize systems that largely depend on the heroism of the individual.
As physicians, we are famously autonomous and value our professional independence, even to the degree that it might harm patients. We generally eschew standardization, believing that each patient is inherently different. In fact, the thrill of the improvisational theater that follows every patient’s chief compliant is one of the great satisfiers in medicine. We love that feeling that comes from sleuthing each case, deftly enacting a plan of action to shepherd the patient to health.
To suggest following protocols, guidelines, and checklists is derisively dismissed as “cookbook medicine.” To work in teams in which certain tasks are delegated to others is seen as weakness—we don’t need a system that utilizes a pharmacist; rather, we should know the doses of all medicines, their interactions, and the effect of renal and liver impairment on their clearance. To suggest otherwise is an insult to our Oslerian roots. To examine our errors, our system breakdowns, our patient harms is anathema to our practice, an admission of failure.
The result is that most of us continue to toil in systems that have become exponentially unsafe as healthcare has become more complex. Today, we still have a system that will more or less allow us to kill a patient by doing nothing more than forgetting the letter “g.” I can go to my hospital today and intend to write “4 grams of magnesium sulfate (MgSO4)” and inadvertently forget the “g” in “Mg.” This could result in an order for a lethal dose of morphine sulfate (MSO4). It’s that easy to hurt a patient. Now, you might say that would never happen, because the pharmacy would catch it. And this is likely. But is it guaranteed? Can you 100% ensure it wouldn’t happen? Consider that nearly 20% of medication doses administered in a hospital are done so incorrectly.2 Nearly 1 in 5. This is the type of system we are employing to stop this lethal overdose. Is this system, which depends on another human to prevent an error, foolproof, or just a snare waiting to prove you the fool?
This represents our opportunity. As hospitalists, the hospital is our tapestry, our system of care, our responsibility. Few others are as well-positioned to ensure that the systems that envelop our patients are highly functional, reliable, and safe. This will take work—work that will feel burdensome, underappreciated, undercompensated. And, fully recognizing that none of us went into medicine to become systems engineers, this will be hard.
However, if not us, who? Who will ensure that our fathers, our mothers, our children will be as safe in the hospital as they are on the drive to the hospital? TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
References
- Global health leaders join the World Health Organization to announce accelerated efforts to improve patient safety. World Health Organization website. Available at: www.who.int/mediacentre/news/releases/2004/pr74/en/. Accessed Feb. 14, 2011.
- Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162(16):1897-1903.
I recently visited my parents in my ancestral home of Wisconsin. As parents of a certain age, they inexplicably are genetically predisposed to owning a minivan. Another quirk of their DNA is that they must own a new minivan. No sooner has the last wisp of new-car smell osmosed from the burled walnut interior than they are trading up to the newest, tricked-out minivan. Perhaps more puzzling is the manner of pride they display in their minivan.
Now, my dad, as if not readily apparent, is not cool. And to see him folded into the driver’s seat, his furry-ear-to-furry-ear grin signaling a self-satisfaction customarily reserved for his grandchildren, painstakingly recounting glory-day stories and 4:30 p.m. dinner buffets, further solidifies his place in the Annals of Uncool.
When I’m home, they tend to employ my chauffeur services (most likely in retribution for my peri-pubescent years), and on the first day back home, I stopped their newest ride near the back door of the house, foot idling on the brake while this exchange occurred: “That’s a fascinating story about how much more challenging the world was when you were my age, Dad. You are a true American hero. Would you like to get out here or in the garage?”
“Here,” he replied.
“OK, then get out,” I countered.
“I can’t,” he responded knowingly.
“Why not?” I queried, the patience seeping from my voice.
“Because the door’s not open,” he answered, seemingly mocking me.
“Then open it,” I replied, silently recounting the evidence for his institutionalization.
“I can’t,” he responded.
“Why not?” I replied again, this time calculating the likelihood that I was adopted.
“Because it’s locked,” came his retort.
“Then unlock it,” I answered, reconfirming my decision to move away for college.
“I can’t,” he replied, ostensibly encouraging parenticide.
“Why not?” I queried, strongly contemplating parenticide.
“Because you haven’t put the car in park,” he responded triumphantly.
A System So Safe
As a safety feature, the minivan needed to be in park before you could open the door to exit. I’ve never heard of anyone actually falling out of a moving car, but recollecting high school, I can fathom the right mix, type, and number of teenagers where possibility would meet inevitability. But, apparently, enough people are falling out of moving vehicles that car engineers have built a system that is so safe, this can’t happen. So no matter how hard someone tries, it just isn’t possible to fall out of a moving car (believe me, toward the end of a week of my father’s car stories, my mind had worked every possible angle).
Likewise, newer vehicles employ occupant-sensitive sensors that detect the weight, size, and position of the passenger to determine if the airbag should deploy. Rather than depending on the driver to turn the passenger-side airbag on or off, the car does it for you: heavy enough to trigger the sensor, and the airbag will deploy; too light, and the car assumes you are a child and doesn’t deploy. It’s a system that is so safe because it doesn’t depend on the operator to get it right.
Ditto motion sensors that detect objects behind the car while reversing (avoiding accidental back-overs), antilock brakes (to maintain control during panicked braking), traction control (improves stability during acceleration), electronic stability control (foils spinouts), tire-pressure-monitoring systems (avoids blowouts), daytime running lights (ensures others see you), rollover airbags (they stay inflated to keep you in the car), lane-departure warning (alerts you if you stray from your lane), and doors that automatically lock after the car starts (again, falling out of cars).
For all the negative press of late, car manufacturers understand safety.
A System Not So Safe
Contrast this to healthcare, in which 10% of patients will suffer a serious, preventable, adverse event during their hospital stay.1 Read that sentence again. That’s 10%; that’s preventable; that’s a number that has largely remained unchanged in the past decade. If 1 in 10 drivers suffered a serious adverse preventable auto accident, Congress would do nothing but hold automotive safety hearings.
In medicine, we still largely employ unsafe systems in which even the best doctors can, and do, hurt patients. Sure, we have made strides in this arena (oxygen tubing that only works if hooked up properly, smart pumps that avert IV dosing errors, CO2 monitors to detect proper endotracheal tube placement), but remarkably, in this era of patient safety, we still utilize systems that largely depend on the heroism of the individual.
As physicians, we are famously autonomous and value our professional independence, even to the degree that it might harm patients. We generally eschew standardization, believing that each patient is inherently different. In fact, the thrill of the improvisational theater that follows every patient’s chief compliant is one of the great satisfiers in medicine. We love that feeling that comes from sleuthing each case, deftly enacting a plan of action to shepherd the patient to health.
To suggest following protocols, guidelines, and checklists is derisively dismissed as “cookbook medicine.” To work in teams in which certain tasks are delegated to others is seen as weakness—we don’t need a system that utilizes a pharmacist; rather, we should know the doses of all medicines, their interactions, and the effect of renal and liver impairment on their clearance. To suggest otherwise is an insult to our Oslerian roots. To examine our errors, our system breakdowns, our patient harms is anathema to our practice, an admission of failure.
The result is that most of us continue to toil in systems that have become exponentially unsafe as healthcare has become more complex. Today, we still have a system that will more or less allow us to kill a patient by doing nothing more than forgetting the letter “g.” I can go to my hospital today and intend to write “4 grams of magnesium sulfate (MgSO4)” and inadvertently forget the “g” in “Mg.” This could result in an order for a lethal dose of morphine sulfate (MSO4). It’s that easy to hurt a patient. Now, you might say that would never happen, because the pharmacy would catch it. And this is likely. But is it guaranteed? Can you 100% ensure it wouldn’t happen? Consider that nearly 20% of medication doses administered in a hospital are done so incorrectly.2 Nearly 1 in 5. This is the type of system we are employing to stop this lethal overdose. Is this system, which depends on another human to prevent an error, foolproof, or just a snare waiting to prove you the fool?
This represents our opportunity. As hospitalists, the hospital is our tapestry, our system of care, our responsibility. Few others are as well-positioned to ensure that the systems that envelop our patients are highly functional, reliable, and safe. This will take work—work that will feel burdensome, underappreciated, undercompensated. And, fully recognizing that none of us went into medicine to become systems engineers, this will be hard.
However, if not us, who? Who will ensure that our fathers, our mothers, our children will be as safe in the hospital as they are on the drive to the hospital? TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
References
- Global health leaders join the World Health Organization to announce accelerated efforts to improve patient safety. World Health Organization website. Available at: www.who.int/mediacentre/news/releases/2004/pr74/en/. Accessed Feb. 14, 2011.
- Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162(16):1897-1903.
POLICY CORNER: An inside look at the most pressing policy issues
This year, hospitalists will begin to see health reform affect the way they work, and SHM is bringing the best perspective and access to its members.
With the proposed rules anticipated to have been in effect by the end of January, the definition and development of accountable care organizations (ACOs) will answer two long-awaited questions: How will these organizations impact the practice of hospital medicine … and when? Additionally, the Community-Based Care Transitions Program available to hospitals identified as having high readmission rates is scheduled to begin in early 2011.
So how can hospitalists get the information they need to prepare for, and succeed under, all of these new rules? Launched in mid-January, our new Advocacy & Public Policy portal at www.hospitalmedicine.org provides summaries and background material for relevant reform provisions, educational resources, headlines, and coming events—along with an easy way to reach out to elected officials through our Legislative Action Center.
Specifically outlined are SHM’s top priority issues (hospital value-based purchasing [HVBP], bundled payments, and reducing readmissions/improving care transitions), identified by the Public Policy Committee. The summaries also include SHM’s position statement so hospitalists know where SHM stands and what we’re doing to help hospitalists best position themselves to succeed.
In addition to provisions of the Affordable Care Act (ACA) of 2010, we’ve devoted a section to health information technology and updated the Physician Quality Reporting System to reflect ACA changes (including Maintenance of Certification [MOC] and the Physician Compare website).
In January, Patrick Conway, MD, and Patrick Torcson, MD, MMM, FACP, SFHM, chairmen of the Public Policy Committee and Performance & Standards Committee, respectively, presented the “Health Reform: Highlights and Practical Implications for Hospitalists” webinar, which explored ACOs, readmissions, HVBP, and the Centers for Medicare & Medicaid Services’ role in the implementation process. If you missed the presentation, it is available on demand at www.hospitalmedicine.org/webinars.
HM11, which is May 10-13 in Grapevine, Texas, will feature a session on the latest reform news: “The Biggest Changes in Healthcare Reform: What We Know Now.” Though the final presentation likely will change in the days leading up to the meeting, the panel plans to review how other ACA provisions will set hospitalists up to succeed under the new ACO model.
Now is the time for hospitalists to get up to speed. TH
Find all this and more by visiting www.hospitalmedicine.org/advocacy and let us know what you think by e-mailing [email protected].
This year, hospitalists will begin to see health reform affect the way they work, and SHM is bringing the best perspective and access to its members.
With the proposed rules anticipated to have been in effect by the end of January, the definition and development of accountable care organizations (ACOs) will answer two long-awaited questions: How will these organizations impact the practice of hospital medicine … and when? Additionally, the Community-Based Care Transitions Program available to hospitals identified as having high readmission rates is scheduled to begin in early 2011.
So how can hospitalists get the information they need to prepare for, and succeed under, all of these new rules? Launched in mid-January, our new Advocacy & Public Policy portal at www.hospitalmedicine.org provides summaries and background material for relevant reform provisions, educational resources, headlines, and coming events—along with an easy way to reach out to elected officials through our Legislative Action Center.
Specifically outlined are SHM’s top priority issues (hospital value-based purchasing [HVBP], bundled payments, and reducing readmissions/improving care transitions), identified by the Public Policy Committee. The summaries also include SHM’s position statement so hospitalists know where SHM stands and what we’re doing to help hospitalists best position themselves to succeed.
In addition to provisions of the Affordable Care Act (ACA) of 2010, we’ve devoted a section to health information technology and updated the Physician Quality Reporting System to reflect ACA changes (including Maintenance of Certification [MOC] and the Physician Compare website).
In January, Patrick Conway, MD, and Patrick Torcson, MD, MMM, FACP, SFHM, chairmen of the Public Policy Committee and Performance & Standards Committee, respectively, presented the “Health Reform: Highlights and Practical Implications for Hospitalists” webinar, which explored ACOs, readmissions, HVBP, and the Centers for Medicare & Medicaid Services’ role in the implementation process. If you missed the presentation, it is available on demand at www.hospitalmedicine.org/webinars.
HM11, which is May 10-13 in Grapevine, Texas, will feature a session on the latest reform news: “The Biggest Changes in Healthcare Reform: What We Know Now.” Though the final presentation likely will change in the days leading up to the meeting, the panel plans to review how other ACA provisions will set hospitalists up to succeed under the new ACO model.
Now is the time for hospitalists to get up to speed. TH
Find all this and more by visiting www.hospitalmedicine.org/advocacy and let us know what you think by e-mailing [email protected].
This year, hospitalists will begin to see health reform affect the way they work, and SHM is bringing the best perspective and access to its members.
With the proposed rules anticipated to have been in effect by the end of January, the definition and development of accountable care organizations (ACOs) will answer two long-awaited questions: How will these organizations impact the practice of hospital medicine … and when? Additionally, the Community-Based Care Transitions Program available to hospitals identified as having high readmission rates is scheduled to begin in early 2011.
So how can hospitalists get the information they need to prepare for, and succeed under, all of these new rules? Launched in mid-January, our new Advocacy & Public Policy portal at www.hospitalmedicine.org provides summaries and background material for relevant reform provisions, educational resources, headlines, and coming events—along with an easy way to reach out to elected officials through our Legislative Action Center.
Specifically outlined are SHM’s top priority issues (hospital value-based purchasing [HVBP], bundled payments, and reducing readmissions/improving care transitions), identified by the Public Policy Committee. The summaries also include SHM’s position statement so hospitalists know where SHM stands and what we’re doing to help hospitalists best position themselves to succeed.
In addition to provisions of the Affordable Care Act (ACA) of 2010, we’ve devoted a section to health information technology and updated the Physician Quality Reporting System to reflect ACA changes (including Maintenance of Certification [MOC] and the Physician Compare website).
In January, Patrick Conway, MD, and Patrick Torcson, MD, MMM, FACP, SFHM, chairmen of the Public Policy Committee and Performance & Standards Committee, respectively, presented the “Health Reform: Highlights and Practical Implications for Hospitalists” webinar, which explored ACOs, readmissions, HVBP, and the Centers for Medicare & Medicaid Services’ role in the implementation process. If you missed the presentation, it is available on demand at www.hospitalmedicine.org/webinars.
HM11, which is May 10-13 in Grapevine, Texas, will feature a session on the latest reform news: “The Biggest Changes in Healthcare Reform: What We Know Now.” Though the final presentation likely will change in the days leading up to the meeting, the panel plans to review how other ACA provisions will set hospitalists up to succeed under the new ACO model.
Now is the time for hospitalists to get up to speed. TH
Find all this and more by visiting www.hospitalmedicine.org/advocacy and let us know what you think by e-mailing [email protected].
Resident Restrictions Fuel HM Program Growth
I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.
Thad Horton, MD
St. Louis
Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.
Basically, the highlights of the new rules are:
- Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
- Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
- PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
- Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
- Residents cannot work more than six consecutive nights as night float; and
- Residents cannot be scheduled for in-house call more frequently than every third night.
I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.
The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.
Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.
If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.
Communication, Comfort Zone Key to Managing Hypertensive Emergencies
I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?
Dennis Swanson, MD
Grand Rapids, Mich.
Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.
Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.
It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH
I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.
Thad Horton, MD
St. Louis
Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.
Basically, the highlights of the new rules are:
- Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
- Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
- PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
- Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
- Residents cannot work more than six consecutive nights as night float; and
- Residents cannot be scheduled for in-house call more frequently than every third night.
I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.
The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.
Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.
If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.
Communication, Comfort Zone Key to Managing Hypertensive Emergencies
I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?
Dennis Swanson, MD
Grand Rapids, Mich.
Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.
Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.
It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH
I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.
Thad Horton, MD
St. Louis
Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.
Basically, the highlights of the new rules are:
- Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
- Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
- PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
- Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
- Residents cannot work more than six consecutive nights as night float; and
- Residents cannot be scheduled for in-house call more frequently than every third night.
I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.
The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.
Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.
If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.
Communication, Comfort Zone Key to Managing Hypertensive Emergencies
I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?
Dennis Swanson, MD
Grand Rapids, Mich.
Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.
Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.
It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH
Turbulence Ahead
After the wild ride of 2010, public-policy watchers could be forgiven for fervently hoping that 2011 offers a calmer year on the healthcare front.
Fat chance.
The turbulence could begin immediately, with the seating of the 112th Congress on Jan. 3. “I think the first question that’s on everybody’s mind is, ‘What will the Republican majority in the House do to Obama’s healthcare reform initiative?’ ” says Eric Siegal, MD, SFHM, a member of SHM’s Public Policy Committee (PPC) and a clinical assistant professor of medicine at the University of Wisconsin School of Medicine and Public Health.
For most issues of direct concern to hospitalists, he says, especially those centered on healthcare delivery, “the wheels were in motion” long before the reform bill became law. Dr. Siegal also says most healthcare experts support the substance of accountable care organizations (ACOs), pay for performance, and reforming Medicare in ways that reward quality instead of quantity. “I think that ship is out of the harbor,” he says.
Throughout the year, the PPC will focus on three priorities identified in the Affordable Care Act: hospital value-based purchasing, bundled payments including ACOs, and hospital readmissions and transitions of care.
—Bill Vaughan, senior policy analyst, Consumers Union, Washington, D.C.
Debate, Delay, Defund?
There are several ways that Congress can delay or thwart the launch of specific reform initiatives. The first is to hold hearings about reform measures, Dr. Siegal says, “with the hope that they can somehow undermine it by raising questions about either the finances of it or about the implications for average Americans in terms of what kind of healthcare they’re going to get.” Such tactics carry significant risk, however, because highlighting specific aspects of the reform law could actually increase overall public support. “It has the potential to backfire on them,” he says.
“Repeal won’t happen anytime soon,” predicts Pat Conway, MD, chair of the PPC and director of hospital medicine at Cincinnati Children’s Hospital. “However, Congress could gut or significantly reduce funding to multiple programs within the bill, and then if you significantly reduce the funding, this may make it nearly impossible for those programs to be successful.”
Rough estimates suggest that some $150 billion worth of programs over the 10-year life of the healthcare reform act remain unfunded and are at risk. As an example, Dr. Conway cites wording in the bill that authorizes a program to help ease patient transitions in and out of the hospital. “If you reduce that funding to near zero, hospitals and hospitalists may still be successful, but you’ve essentially removed the program to learn how to be successful,” he says.
Bill Vaughan, a senior policy analyst in healthcare with the Washington, D.C.-based organization Consumers Union, says targeted riders could be added to appropriations bills. For instance, one rider could prohibit the Centers for Medicare & Medicaid Services (CMS) from spending any money to help develop government-supported insurance exchanges. Another could prevent the IRS from collecting money to be channeled into the trust fund for the Patient-Centered Outcomes Research Institute and its focus on comparative-effectiveness research. “There’s no end to mischief,” Vaughan says. “There are as many opportunities as the day is long.”
A major confrontation could arrive in March or April, when the U.S. runs into its debt ceiling. A continuing resolution would then be required to continue the appropriations process (and increase the U.S. debt ceiling past its current limit of $14.3 trillion). At that point or soon thereafter, Vaughan says, an opportunity could arise for legislators to say they won’t vote for a critical appropriations bill unless it includes certain spending reductions cited by one of several commissions tasked with recommending ways to reduce the deficit. “That could include hospital cuts, more doctor cuts, significant cost shifting to beneficiaries, higher copays,” he says.
Amid a “firestorm of ideas” on how to further cut Medicare and Medicaid spending, ideas once deemed radical could gain more traction. Some legislators have tossed around the idea of shutting down the government, if need be. “There’s nothing on the radar scope but static and fuzz,” Vaughan says. “It is totally unclear what is going to happen.”
Dearth of Drugs
Another trend generating both uncertainty and headaches in the nation’s hospitals is an unprecedented prescription drug shortage that could last well into the New Year, based on the number of medicines now in scarce supply across the country. In mid-November, for example, the American Society of Clinical Oncology announced “severe and worsening shortages of many critical therapies,” including doxorubicin, leucovorin, etoposide, nitrogen mustard, vincristine, propofol, and morphine.
Valerie Jensen, associate director of the FDA’s drug shortage program, told the Associated Press that her agency was seeing a record number of drug shortfalls in 2010. In mid-November, the FDA’s Current Drug Shortages list (www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm) included multiple formulations of 50 different medicines. Why so many? Jensen blamed the scarcity, in part, on the fact that many older drugs are not as profitable as newer ones. Manufacturing issues or delays and increased demand were the two biggest official reasons, though the FDA reported that at least eight formulations had been pulled or held from the market.
Vaughan says he’s heard plenty of buzz about the problem showing up quickly and unexpectedly in hospitals. Drug companies are supposed to give the FDA six months’ notice if they stop producing a drug, he says, but there’s no penalty if they don’t. “It’s amazing the number of people who are starting to worry about it,” he says. TH
Bryn Nelson is a freelance medical writer based in Seattle.
After the wild ride of 2010, public-policy watchers could be forgiven for fervently hoping that 2011 offers a calmer year on the healthcare front.
Fat chance.
The turbulence could begin immediately, with the seating of the 112th Congress on Jan. 3. “I think the first question that’s on everybody’s mind is, ‘What will the Republican majority in the House do to Obama’s healthcare reform initiative?’ ” says Eric Siegal, MD, SFHM, a member of SHM’s Public Policy Committee (PPC) and a clinical assistant professor of medicine at the University of Wisconsin School of Medicine and Public Health.
For most issues of direct concern to hospitalists, he says, especially those centered on healthcare delivery, “the wheels were in motion” long before the reform bill became law. Dr. Siegal also says most healthcare experts support the substance of accountable care organizations (ACOs), pay for performance, and reforming Medicare in ways that reward quality instead of quantity. “I think that ship is out of the harbor,” he says.
Throughout the year, the PPC will focus on three priorities identified in the Affordable Care Act: hospital value-based purchasing, bundled payments including ACOs, and hospital readmissions and transitions of care.
—Bill Vaughan, senior policy analyst, Consumers Union, Washington, D.C.
Debate, Delay, Defund?
There are several ways that Congress can delay or thwart the launch of specific reform initiatives. The first is to hold hearings about reform measures, Dr. Siegal says, “with the hope that they can somehow undermine it by raising questions about either the finances of it or about the implications for average Americans in terms of what kind of healthcare they’re going to get.” Such tactics carry significant risk, however, because highlighting specific aspects of the reform law could actually increase overall public support. “It has the potential to backfire on them,” he says.
“Repeal won’t happen anytime soon,” predicts Pat Conway, MD, chair of the PPC and director of hospital medicine at Cincinnati Children’s Hospital. “However, Congress could gut or significantly reduce funding to multiple programs within the bill, and then if you significantly reduce the funding, this may make it nearly impossible for those programs to be successful.”
Rough estimates suggest that some $150 billion worth of programs over the 10-year life of the healthcare reform act remain unfunded and are at risk. As an example, Dr. Conway cites wording in the bill that authorizes a program to help ease patient transitions in and out of the hospital. “If you reduce that funding to near zero, hospitals and hospitalists may still be successful, but you’ve essentially removed the program to learn how to be successful,” he says.
Bill Vaughan, a senior policy analyst in healthcare with the Washington, D.C.-based organization Consumers Union, says targeted riders could be added to appropriations bills. For instance, one rider could prohibit the Centers for Medicare & Medicaid Services (CMS) from spending any money to help develop government-supported insurance exchanges. Another could prevent the IRS from collecting money to be channeled into the trust fund for the Patient-Centered Outcomes Research Institute and its focus on comparative-effectiveness research. “There’s no end to mischief,” Vaughan says. “There are as many opportunities as the day is long.”
A major confrontation could arrive in March or April, when the U.S. runs into its debt ceiling. A continuing resolution would then be required to continue the appropriations process (and increase the U.S. debt ceiling past its current limit of $14.3 trillion). At that point or soon thereafter, Vaughan says, an opportunity could arise for legislators to say they won’t vote for a critical appropriations bill unless it includes certain spending reductions cited by one of several commissions tasked with recommending ways to reduce the deficit. “That could include hospital cuts, more doctor cuts, significant cost shifting to beneficiaries, higher copays,” he says.
Amid a “firestorm of ideas” on how to further cut Medicare and Medicaid spending, ideas once deemed radical could gain more traction. Some legislators have tossed around the idea of shutting down the government, if need be. “There’s nothing on the radar scope but static and fuzz,” Vaughan says. “It is totally unclear what is going to happen.”
Dearth of Drugs
Another trend generating both uncertainty and headaches in the nation’s hospitals is an unprecedented prescription drug shortage that could last well into the New Year, based on the number of medicines now in scarce supply across the country. In mid-November, for example, the American Society of Clinical Oncology announced “severe and worsening shortages of many critical therapies,” including doxorubicin, leucovorin, etoposide, nitrogen mustard, vincristine, propofol, and morphine.
Valerie Jensen, associate director of the FDA’s drug shortage program, told the Associated Press that her agency was seeing a record number of drug shortfalls in 2010. In mid-November, the FDA’s Current Drug Shortages list (www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm) included multiple formulations of 50 different medicines. Why so many? Jensen blamed the scarcity, in part, on the fact that many older drugs are not as profitable as newer ones. Manufacturing issues or delays and increased demand were the two biggest official reasons, though the FDA reported that at least eight formulations had been pulled or held from the market.
Vaughan says he’s heard plenty of buzz about the problem showing up quickly and unexpectedly in hospitals. Drug companies are supposed to give the FDA six months’ notice if they stop producing a drug, he says, but there’s no penalty if they don’t. “It’s amazing the number of people who are starting to worry about it,” he says. TH
Bryn Nelson is a freelance medical writer based in Seattle.
After the wild ride of 2010, public-policy watchers could be forgiven for fervently hoping that 2011 offers a calmer year on the healthcare front.
Fat chance.
The turbulence could begin immediately, with the seating of the 112th Congress on Jan. 3. “I think the first question that’s on everybody’s mind is, ‘What will the Republican majority in the House do to Obama’s healthcare reform initiative?’ ” says Eric Siegal, MD, SFHM, a member of SHM’s Public Policy Committee (PPC) and a clinical assistant professor of medicine at the University of Wisconsin School of Medicine and Public Health.
For most issues of direct concern to hospitalists, he says, especially those centered on healthcare delivery, “the wheels were in motion” long before the reform bill became law. Dr. Siegal also says most healthcare experts support the substance of accountable care organizations (ACOs), pay for performance, and reforming Medicare in ways that reward quality instead of quantity. “I think that ship is out of the harbor,” he says.
Throughout the year, the PPC will focus on three priorities identified in the Affordable Care Act: hospital value-based purchasing, bundled payments including ACOs, and hospital readmissions and transitions of care.
—Bill Vaughan, senior policy analyst, Consumers Union, Washington, D.C.
Debate, Delay, Defund?
There are several ways that Congress can delay or thwart the launch of specific reform initiatives. The first is to hold hearings about reform measures, Dr. Siegal says, “with the hope that they can somehow undermine it by raising questions about either the finances of it or about the implications for average Americans in terms of what kind of healthcare they’re going to get.” Such tactics carry significant risk, however, because highlighting specific aspects of the reform law could actually increase overall public support. “It has the potential to backfire on them,” he says.
“Repeal won’t happen anytime soon,” predicts Pat Conway, MD, chair of the PPC and director of hospital medicine at Cincinnati Children’s Hospital. “However, Congress could gut or significantly reduce funding to multiple programs within the bill, and then if you significantly reduce the funding, this may make it nearly impossible for those programs to be successful.”
Rough estimates suggest that some $150 billion worth of programs over the 10-year life of the healthcare reform act remain unfunded and are at risk. As an example, Dr. Conway cites wording in the bill that authorizes a program to help ease patient transitions in and out of the hospital. “If you reduce that funding to near zero, hospitals and hospitalists may still be successful, but you’ve essentially removed the program to learn how to be successful,” he says.
Bill Vaughan, a senior policy analyst in healthcare with the Washington, D.C.-based organization Consumers Union, says targeted riders could be added to appropriations bills. For instance, one rider could prohibit the Centers for Medicare & Medicaid Services (CMS) from spending any money to help develop government-supported insurance exchanges. Another could prevent the IRS from collecting money to be channeled into the trust fund for the Patient-Centered Outcomes Research Institute and its focus on comparative-effectiveness research. “There’s no end to mischief,” Vaughan says. “There are as many opportunities as the day is long.”
A major confrontation could arrive in March or April, when the U.S. runs into its debt ceiling. A continuing resolution would then be required to continue the appropriations process (and increase the U.S. debt ceiling past its current limit of $14.3 trillion). At that point or soon thereafter, Vaughan says, an opportunity could arise for legislators to say they won’t vote for a critical appropriations bill unless it includes certain spending reductions cited by one of several commissions tasked with recommending ways to reduce the deficit. “That could include hospital cuts, more doctor cuts, significant cost shifting to beneficiaries, higher copays,” he says.
Amid a “firestorm of ideas” on how to further cut Medicare and Medicaid spending, ideas once deemed radical could gain more traction. Some legislators have tossed around the idea of shutting down the government, if need be. “There’s nothing on the radar scope but static and fuzz,” Vaughan says. “It is totally unclear what is going to happen.”
Dearth of Drugs
Another trend generating both uncertainty and headaches in the nation’s hospitals is an unprecedented prescription drug shortage that could last well into the New Year, based on the number of medicines now in scarce supply across the country. In mid-November, for example, the American Society of Clinical Oncology announced “severe and worsening shortages of many critical therapies,” including doxorubicin, leucovorin, etoposide, nitrogen mustard, vincristine, propofol, and morphine.
Valerie Jensen, associate director of the FDA’s drug shortage program, told the Associated Press that her agency was seeing a record number of drug shortfalls in 2010. In mid-November, the FDA’s Current Drug Shortages list (www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm) included multiple formulations of 50 different medicines. Why so many? Jensen blamed the scarcity, in part, on the fact that many older drugs are not as profitable as newer ones. Manufacturing issues or delays and increased demand were the two biggest official reasons, though the FDA reported that at least eight formulations had been pulled or held from the market.
Vaughan says he’s heard plenty of buzz about the problem showing up quickly and unexpectedly in hospitals. Drug companies are supposed to give the FDA six months’ notice if they stop producing a drug, he says, but there’s no penalty if they don’t. “It’s amazing the number of people who are starting to worry about it,” he says. TH
Bryn Nelson is a freelance medical writer based in Seattle.
NEW FEATURE: POLICY CORNER: An inside look at the most pressing policy issues (updated 01.04.2011)
The Centers for Medicare & Medicaid Services (CMS) in November announced the official launch of the Center for Medicare & Medicaid Innovation (CMMI). The CMI was authorized under the Affordable Care Act (ACA) to test innovative ways to reduce costs, while preserving or enhancing the quality. This sounds very similar to many other reform initiatives, so why have a separate center when ACOs, value-based purchasing, and payment bundling already are in the ACA?
A quick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents. Don Berwick, MD, the new CMS administrator, has even gone so far as to call the center the “jewel in the crown” of the ACA.
Inspirational language aside, the center can be summed up using a simple analogy: The “other” ACA initiatives (bundling, VBP, etc.) are like a factory floor. The tools are in place, the processes are more or less defined, and they will be carried out regardless of the degree of positive impact. CMMI is more like a research and development lab, with the freedom to tinker with new ideas before wide-scale implementation.
The keys to CMMI success are twofold. First, it will implement pilot projects rather than demonstrations. A pilot gives the Secretary of Health and Human Services the power to implement and expand promising projects without Congressional approval. A demonstration requires Congressional approval for its continuation.. Second, CMMI does not require proposals to be budget neutral. Initial training and staffing costs alone can disqualify a program on budget neutrality grounds. Since CMMI does not require budget neutrality, promising programs with significant start-up costs are less likely to be cast aside.
Dr. Berwick has asked for provider partnership and input, and says he “would like to help forge an unprecedented level of shared aim, shared vision, and synergy in action among the public and private stewards and leaders of healthcare.” This vision and a $10 billion appropriation over the next decade present a tremendous opportunity for SHM’s quality initiatives, and the promising hospitalist-created protocol.
However, this large appropriation presents both the greatest strength and the greatest threat to the center. With the Republican takeover of the House of Representatives, the CMMI budget likely is to be a target for the “repeal, replace, or revise” agenda. Therefore, increasing awareness of CMMI’s role will be imperative over the coming months. Hospitalists can help by educating themselves, then passing their knowledge along to those who might not understand the importance of the center. TH
The Centers for Medicare & Medicaid Services (CMS) in November announced the official launch of the Center for Medicare & Medicaid Innovation (CMMI). The CMI was authorized under the Affordable Care Act (ACA) to test innovative ways to reduce costs, while preserving or enhancing the quality. This sounds very similar to many other reform initiatives, so why have a separate center when ACOs, value-based purchasing, and payment bundling already are in the ACA?
A quick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents. Don Berwick, MD, the new CMS administrator, has even gone so far as to call the center the “jewel in the crown” of the ACA.
Inspirational language aside, the center can be summed up using a simple analogy: The “other” ACA initiatives (bundling, VBP, etc.) are like a factory floor. The tools are in place, the processes are more or less defined, and they will be carried out regardless of the degree of positive impact. CMMI is more like a research and development lab, with the freedom to tinker with new ideas before wide-scale implementation.
The keys to CMMI success are twofold. First, it will implement pilot projects rather than demonstrations. A pilot gives the Secretary of Health and Human Services the power to implement and expand promising projects without Congressional approval. A demonstration requires Congressional approval for its continuation.. Second, CMMI does not require proposals to be budget neutral. Initial training and staffing costs alone can disqualify a program on budget neutrality grounds. Since CMMI does not require budget neutrality, promising programs with significant start-up costs are less likely to be cast aside.
Dr. Berwick has asked for provider partnership and input, and says he “would like to help forge an unprecedented level of shared aim, shared vision, and synergy in action among the public and private stewards and leaders of healthcare.” This vision and a $10 billion appropriation over the next decade present a tremendous opportunity for SHM’s quality initiatives, and the promising hospitalist-created protocol.
However, this large appropriation presents both the greatest strength and the greatest threat to the center. With the Republican takeover of the House of Representatives, the CMMI budget likely is to be a target for the “repeal, replace, or revise” agenda. Therefore, increasing awareness of CMMI’s role will be imperative over the coming months. Hospitalists can help by educating themselves, then passing their knowledge along to those who might not understand the importance of the center. TH
The Centers for Medicare & Medicaid Services (CMS) in November announced the official launch of the Center for Medicare & Medicaid Innovation (CMMI). The CMI was authorized under the Affordable Care Act (ACA) to test innovative ways to reduce costs, while preserving or enhancing the quality. This sounds very similar to many other reform initiatives, so why have a separate center when ACOs, value-based purchasing, and payment bundling already are in the ACA?
A quick glance at the CMMI website didn’t provide much detail beyond uplifting language about the promise that the center represents. Don Berwick, MD, the new CMS administrator, has even gone so far as to call the center the “jewel in the crown” of the ACA.
Inspirational language aside, the center can be summed up using a simple analogy: The “other” ACA initiatives (bundling, VBP, etc.) are like a factory floor. The tools are in place, the processes are more or less defined, and they will be carried out regardless of the degree of positive impact. CMMI is more like a research and development lab, with the freedom to tinker with new ideas before wide-scale implementation.
The keys to CMMI success are twofold. First, it will implement pilot projects rather than demonstrations. A pilot gives the Secretary of Health and Human Services the power to implement and expand promising projects without Congressional approval. A demonstration requires Congressional approval for its continuation.. Second, CMMI does not require proposals to be budget neutral. Initial training and staffing costs alone can disqualify a program on budget neutrality grounds. Since CMMI does not require budget neutrality, promising programs with significant start-up costs are less likely to be cast aside.
Dr. Berwick has asked for provider partnership and input, and says he “would like to help forge an unprecedented level of shared aim, shared vision, and synergy in action among the public and private stewards and leaders of healthcare.” This vision and a $10 billion appropriation over the next decade present a tremendous opportunity for SHM’s quality initiatives, and the promising hospitalist-created protocol.
However, this large appropriation presents both the greatest strength and the greatest threat to the center. With the Republican takeover of the House of Representatives, the CMMI budget likely is to be a target for the “repeal, replace, or revise” agenda. Therefore, increasing awareness of CMMI’s role will be imperative over the coming months. Hospitalists can help by educating themselves, then passing their knowledge along to those who might not understand the importance of the center. TH
The Medicaid Gap
Amid the recent focus on Medicare’s spiraling costs and efforts to rein in government spending, media accounts have painted a grim picture of Medicaid financing as well:
- With record enrollment, Kentucky’s Medicaid program is facing a budget shortfall of nearly $500 million. In Arizona, the gap is expected to be $1 billion.
- In September, Washington state announced $112.8 million in Medicaid cuts, a reduction that the state’s Medicaid director described as “devastating.”
- According to the Kaiser Family Foundation, Louisiana cut Medicaid inpatient hospital rates 3.5% in fiscal year 2009, 12.1% in 2010, and an additional 4.6% for 2011 to help close budget gaps.
- Maine politicians are facing off over a $380 million state debt owed to hospitals providing Medicaid services.
Safety-net hospitals that care for a disproportionate share of uninsured and Medicaid patients are likely to feel the most pain. So what does that mean for hospitalists? Experts say they will be increasingly looked to for guidance and leadership in identifying cost-saving measures and in helping hospitals avoid further penalties by focusing on such critical metrics as readmission rates.
Political ‘Hot Potato’
The pressure isn’t likely to ease anytime soon. The American Recovery and Reinvestment Act provided $87 billion to help states pay for Medicaid costs from October 2008 through the end of this year by temporarily boosting the federal Medicaid matching rate, officially known as the Federal Medical Assistance Percentages (FMAP). In August, Congress passed legislation that provided an additional $16.1 billion to provide six more months of scaled-back relief through June, when the fiscal year ends in most states.
That’s when things could get really sticky. According to an annual survey conducted by the Kaiser Family Foundation, average state spending on Medicaid jumped 8.8% last year, the biggest increase in eight years and higher than the initial prediction of 6.3%. State Medicaid officials reported swelling ranks of eligible families due to the recession as a main reason for the rise. The pace is expected to cool slightly next year, but states that had relied heavily on federal aid to meet budget shortfalls are now facing the prospect of doing without amid a continued expansion of Medicaid enrollees.
“That’s the catch-22 that you’re in right now,” says Ellen Kugler, executive director of the National Association of Urban Hospitals, based in Sterling, Va. “There is increased demand and increasing numbers of uninsured. States are still in fiscal crisis, and there’s a delay before new dollars become available.”
New federal funds become available in 2014 to help pay for insuring those who currently lack insurance. That money will flow either through subsidies to state-administered exchanges or through direct Medicaid payments. But that same year, Kugler says, safety-net hospitals will begin seeing hefty reductions in Medicare disproportionate share (DSH) payments and possibly Medicaid DSH payments, too.
In theory, more people will have some form of health insurance by then, lessening the need to pay hospitals to help them recoup the cost of treating uninsured and underinsured patients. However, Kugler is urging caution on the DSH pay cuts, warning that it’s not clear what the ranks of the newly insured will be. Current projections, she says, suggest that half of those insured patients will fall under Medicaid programs, meaning that significant cuts could pose a financial hardship to hospitals that serve those populations.
Beyond reductions in services and reimbursement rates to doctors and hospitals, few politicians have had the stomach to propose major overhauls in how Medicaid is managed and financed. In New York state, however, a suite of proposals by Lt. Gov. Richard Ravitch has earned praise from The New York Times.1 One would streamline management of the program, now administered by 58 local governments and multiple state agencies. Ravitch also supports reducing the political wrangling over how reimbursement fees are calculated by wresting that power away from the state legislature and giving it to the state’s Medicaid director, who would be advised by an expert panel.
Another unresolved issue is how to pay for the long-term care of chronically ill patients, which in New York accounts for nearly half of its Medicaid spending. Kugler says the high incidence of chronic conditions, including mental illness, among patients in urban settings can contribute to the high readmission rates the new law is set to begin penalizing in 2012. Other studies have found that among Medicaid patients at high risk for frequent hospital admissions, substance abuse can be a major contributor.2
The difficult task, then, is to ensure that the hospitals serving these populations don’t lose even more resources through penalties due to subpar quality metrics. “Do the legwork now. Get your IT systems in place to be able to provide the coordinated care,” Kugler advises. Identifying efficiencies while maintaining the appropriate level of care will be key, whether in appropriate reductions in length of stay or in increased focus on communication with outpatient providers and other forms of outreach.
Hope for the Safety Net
Despite the financial and logistical challenges, Lenny Lopez, MD, MPH, a hospitalist at Brigham and Women’s Hospital and an assistant in health policy at Massachusetts General Hospital, both in Boston, says the situation is far from hopeless for safety-net hospitals. “The idea that if you’re a DSH hospital you’re somehow pegged and destined to provide low-quality care—that does not have to be the case,” he says. Nor do problems such as disparities in how patients are treated necessarily require expensive solutions.
In a recent paper in Academic Emergency Medicine, Dr. Lopez and his colleagues found that among patients with chest pain admitted to EDs, blacks, Hispanics, and those who lacked insurance or were on Medicare were less likely to receive urgent triage care.3 “These are problems that are fixable in a low-cost way,” he argues. “We don’t need another fancy machine to diagnose chest pain.” Rather, he suggests, the problem is really one of quality improvement that centers on boosting guidelines, not buying more equipment or involving more personnel.
Properly defining the problem, Dr. Lopez says, can lead to effective measures to boost quality. Amid the continuing budget crunch, pinpointing where interventions could provide the biggest bang for the buck also might prove enormously helpful.
Of the roughly 4,200 acute-care hospitals in the country, Dr. Lopez and his colleagues found that less than 10% care for the bulk of minority patients, and those on Medicaid or lacking insurance. That means such care is concentrated in about 400 hospitals, “which is a huge opportunity for intervention options for this kind of an issue,” he says. TH
Bryn Nelson is a freelance medical writer based in Seattle.
References
- 1. Benefits and burdens of Medicaid. The New York Times website. Available at: www.nytimes.com/2010/09/22/opinion/22wed2.html?_r=2&hp. Accessed Oct. 23, 2010.
- 2. Raven MC, Billings JC, Goldfrank LR, Manheimer ED, Gourevitch MN. Medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks. J Urban Health. 2009;86(2):230-241.
- 3. López L, Wilper AP, Cervantes MC, Betancourt JR, Green AR. Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006. Acad Emerg Med. 2010:17 (8):801-810.
Amid the recent focus on Medicare’s spiraling costs and efforts to rein in government spending, media accounts have painted a grim picture of Medicaid financing as well:
- With record enrollment, Kentucky’s Medicaid program is facing a budget shortfall of nearly $500 million. In Arizona, the gap is expected to be $1 billion.
- In September, Washington state announced $112.8 million in Medicaid cuts, a reduction that the state’s Medicaid director described as “devastating.”
- According to the Kaiser Family Foundation, Louisiana cut Medicaid inpatient hospital rates 3.5% in fiscal year 2009, 12.1% in 2010, and an additional 4.6% for 2011 to help close budget gaps.
- Maine politicians are facing off over a $380 million state debt owed to hospitals providing Medicaid services.
Safety-net hospitals that care for a disproportionate share of uninsured and Medicaid patients are likely to feel the most pain. So what does that mean for hospitalists? Experts say they will be increasingly looked to for guidance and leadership in identifying cost-saving measures and in helping hospitals avoid further penalties by focusing on such critical metrics as readmission rates.
Political ‘Hot Potato’
The pressure isn’t likely to ease anytime soon. The American Recovery and Reinvestment Act provided $87 billion to help states pay for Medicaid costs from October 2008 through the end of this year by temporarily boosting the federal Medicaid matching rate, officially known as the Federal Medical Assistance Percentages (FMAP). In August, Congress passed legislation that provided an additional $16.1 billion to provide six more months of scaled-back relief through June, when the fiscal year ends in most states.
That’s when things could get really sticky. According to an annual survey conducted by the Kaiser Family Foundation, average state spending on Medicaid jumped 8.8% last year, the biggest increase in eight years and higher than the initial prediction of 6.3%. State Medicaid officials reported swelling ranks of eligible families due to the recession as a main reason for the rise. The pace is expected to cool slightly next year, but states that had relied heavily on federal aid to meet budget shortfalls are now facing the prospect of doing without amid a continued expansion of Medicaid enrollees.
“That’s the catch-22 that you’re in right now,” says Ellen Kugler, executive director of the National Association of Urban Hospitals, based in Sterling, Va. “There is increased demand and increasing numbers of uninsured. States are still in fiscal crisis, and there’s a delay before new dollars become available.”
New federal funds become available in 2014 to help pay for insuring those who currently lack insurance. That money will flow either through subsidies to state-administered exchanges or through direct Medicaid payments. But that same year, Kugler says, safety-net hospitals will begin seeing hefty reductions in Medicare disproportionate share (DSH) payments and possibly Medicaid DSH payments, too.
In theory, more people will have some form of health insurance by then, lessening the need to pay hospitals to help them recoup the cost of treating uninsured and underinsured patients. However, Kugler is urging caution on the DSH pay cuts, warning that it’s not clear what the ranks of the newly insured will be. Current projections, she says, suggest that half of those insured patients will fall under Medicaid programs, meaning that significant cuts could pose a financial hardship to hospitals that serve those populations.
Beyond reductions in services and reimbursement rates to doctors and hospitals, few politicians have had the stomach to propose major overhauls in how Medicaid is managed and financed. In New York state, however, a suite of proposals by Lt. Gov. Richard Ravitch has earned praise from The New York Times.1 One would streamline management of the program, now administered by 58 local governments and multiple state agencies. Ravitch also supports reducing the political wrangling over how reimbursement fees are calculated by wresting that power away from the state legislature and giving it to the state’s Medicaid director, who would be advised by an expert panel.
Another unresolved issue is how to pay for the long-term care of chronically ill patients, which in New York accounts for nearly half of its Medicaid spending. Kugler says the high incidence of chronic conditions, including mental illness, among patients in urban settings can contribute to the high readmission rates the new law is set to begin penalizing in 2012. Other studies have found that among Medicaid patients at high risk for frequent hospital admissions, substance abuse can be a major contributor.2
The difficult task, then, is to ensure that the hospitals serving these populations don’t lose even more resources through penalties due to subpar quality metrics. “Do the legwork now. Get your IT systems in place to be able to provide the coordinated care,” Kugler advises. Identifying efficiencies while maintaining the appropriate level of care will be key, whether in appropriate reductions in length of stay or in increased focus on communication with outpatient providers and other forms of outreach.
Hope for the Safety Net
Despite the financial and logistical challenges, Lenny Lopez, MD, MPH, a hospitalist at Brigham and Women’s Hospital and an assistant in health policy at Massachusetts General Hospital, both in Boston, says the situation is far from hopeless for safety-net hospitals. “The idea that if you’re a DSH hospital you’re somehow pegged and destined to provide low-quality care—that does not have to be the case,” he says. Nor do problems such as disparities in how patients are treated necessarily require expensive solutions.
In a recent paper in Academic Emergency Medicine, Dr. Lopez and his colleagues found that among patients with chest pain admitted to EDs, blacks, Hispanics, and those who lacked insurance or were on Medicare were less likely to receive urgent triage care.3 “These are problems that are fixable in a low-cost way,” he argues. “We don’t need another fancy machine to diagnose chest pain.” Rather, he suggests, the problem is really one of quality improvement that centers on boosting guidelines, not buying more equipment or involving more personnel.
Properly defining the problem, Dr. Lopez says, can lead to effective measures to boost quality. Amid the continuing budget crunch, pinpointing where interventions could provide the biggest bang for the buck also might prove enormously helpful.
Of the roughly 4,200 acute-care hospitals in the country, Dr. Lopez and his colleagues found that less than 10% care for the bulk of minority patients, and those on Medicaid or lacking insurance. That means such care is concentrated in about 400 hospitals, “which is a huge opportunity for intervention options for this kind of an issue,” he says. TH
Bryn Nelson is a freelance medical writer based in Seattle.
References
- 1. Benefits and burdens of Medicaid. The New York Times website. Available at: www.nytimes.com/2010/09/22/opinion/22wed2.html?_r=2&hp. Accessed Oct. 23, 2010.
- 2. Raven MC, Billings JC, Goldfrank LR, Manheimer ED, Gourevitch MN. Medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks. J Urban Health. 2009;86(2):230-241.
- 3. López L, Wilper AP, Cervantes MC, Betancourt JR, Green AR. Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006. Acad Emerg Med. 2010:17 (8):801-810.
Amid the recent focus on Medicare’s spiraling costs and efforts to rein in government spending, media accounts have painted a grim picture of Medicaid financing as well:
- With record enrollment, Kentucky’s Medicaid program is facing a budget shortfall of nearly $500 million. In Arizona, the gap is expected to be $1 billion.
- In September, Washington state announced $112.8 million in Medicaid cuts, a reduction that the state’s Medicaid director described as “devastating.”
- According to the Kaiser Family Foundation, Louisiana cut Medicaid inpatient hospital rates 3.5% in fiscal year 2009, 12.1% in 2010, and an additional 4.6% for 2011 to help close budget gaps.
- Maine politicians are facing off over a $380 million state debt owed to hospitals providing Medicaid services.
Safety-net hospitals that care for a disproportionate share of uninsured and Medicaid patients are likely to feel the most pain. So what does that mean for hospitalists? Experts say they will be increasingly looked to for guidance and leadership in identifying cost-saving measures and in helping hospitals avoid further penalties by focusing on such critical metrics as readmission rates.
Political ‘Hot Potato’
The pressure isn’t likely to ease anytime soon. The American Recovery and Reinvestment Act provided $87 billion to help states pay for Medicaid costs from October 2008 through the end of this year by temporarily boosting the federal Medicaid matching rate, officially known as the Federal Medical Assistance Percentages (FMAP). In August, Congress passed legislation that provided an additional $16.1 billion to provide six more months of scaled-back relief through June, when the fiscal year ends in most states.
That’s when things could get really sticky. According to an annual survey conducted by the Kaiser Family Foundation, average state spending on Medicaid jumped 8.8% last year, the biggest increase in eight years and higher than the initial prediction of 6.3%. State Medicaid officials reported swelling ranks of eligible families due to the recession as a main reason for the rise. The pace is expected to cool slightly next year, but states that had relied heavily on federal aid to meet budget shortfalls are now facing the prospect of doing without amid a continued expansion of Medicaid enrollees.
“That’s the catch-22 that you’re in right now,” says Ellen Kugler, executive director of the National Association of Urban Hospitals, based in Sterling, Va. “There is increased demand and increasing numbers of uninsured. States are still in fiscal crisis, and there’s a delay before new dollars become available.”
New federal funds become available in 2014 to help pay for insuring those who currently lack insurance. That money will flow either through subsidies to state-administered exchanges or through direct Medicaid payments. But that same year, Kugler says, safety-net hospitals will begin seeing hefty reductions in Medicare disproportionate share (DSH) payments and possibly Medicaid DSH payments, too.
In theory, more people will have some form of health insurance by then, lessening the need to pay hospitals to help them recoup the cost of treating uninsured and underinsured patients. However, Kugler is urging caution on the DSH pay cuts, warning that it’s not clear what the ranks of the newly insured will be. Current projections, she says, suggest that half of those insured patients will fall under Medicaid programs, meaning that significant cuts could pose a financial hardship to hospitals that serve those populations.
Beyond reductions in services and reimbursement rates to doctors and hospitals, few politicians have had the stomach to propose major overhauls in how Medicaid is managed and financed. In New York state, however, a suite of proposals by Lt. Gov. Richard Ravitch has earned praise from The New York Times.1 One would streamline management of the program, now administered by 58 local governments and multiple state agencies. Ravitch also supports reducing the political wrangling over how reimbursement fees are calculated by wresting that power away from the state legislature and giving it to the state’s Medicaid director, who would be advised by an expert panel.
Another unresolved issue is how to pay for the long-term care of chronically ill patients, which in New York accounts for nearly half of its Medicaid spending. Kugler says the high incidence of chronic conditions, including mental illness, among patients in urban settings can contribute to the high readmission rates the new law is set to begin penalizing in 2012. Other studies have found that among Medicaid patients at high risk for frequent hospital admissions, substance abuse can be a major contributor.2
The difficult task, then, is to ensure that the hospitals serving these populations don’t lose even more resources through penalties due to subpar quality metrics. “Do the legwork now. Get your IT systems in place to be able to provide the coordinated care,” Kugler advises. Identifying efficiencies while maintaining the appropriate level of care will be key, whether in appropriate reductions in length of stay or in increased focus on communication with outpatient providers and other forms of outreach.
Hope for the Safety Net
Despite the financial and logistical challenges, Lenny Lopez, MD, MPH, a hospitalist at Brigham and Women’s Hospital and an assistant in health policy at Massachusetts General Hospital, both in Boston, says the situation is far from hopeless for safety-net hospitals. “The idea that if you’re a DSH hospital you’re somehow pegged and destined to provide low-quality care—that does not have to be the case,” he says. Nor do problems such as disparities in how patients are treated necessarily require expensive solutions.
In a recent paper in Academic Emergency Medicine, Dr. Lopez and his colleagues found that among patients with chest pain admitted to EDs, blacks, Hispanics, and those who lacked insurance or were on Medicare were less likely to receive urgent triage care.3 “These are problems that are fixable in a low-cost way,” he argues. “We don’t need another fancy machine to diagnose chest pain.” Rather, he suggests, the problem is really one of quality improvement that centers on boosting guidelines, not buying more equipment or involving more personnel.
Properly defining the problem, Dr. Lopez says, can lead to effective measures to boost quality. Amid the continuing budget crunch, pinpointing where interventions could provide the biggest bang for the buck also might prove enormously helpful.
Of the roughly 4,200 acute-care hospitals in the country, Dr. Lopez and his colleagues found that less than 10% care for the bulk of minority patients, and those on Medicaid or lacking insurance. That means such care is concentrated in about 400 hospitals, “which is a huge opportunity for intervention options for this kind of an issue,” he says. TH
Bryn Nelson is a freelance medical writer based in Seattle.
References
- 1. Benefits and burdens of Medicaid. The New York Times website. Available at: www.nytimes.com/2010/09/22/opinion/22wed2.html?_r=2&hp. Accessed Oct. 23, 2010.
- 2. Raven MC, Billings JC, Goldfrank LR, Manheimer ED, Gourevitch MN. Medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks. J Urban Health. 2009;86(2):230-241.
- 3. López L, Wilper AP, Cervantes MC, Betancourt JR, Green AR. Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006. Acad Emerg Med. 2010:17 (8):801-810.