Big Changes Ahead: Medicare IPPS 2012 and What It Means for Hospitals (Becker’s Hospital Review)0

The following article first appeared at Becker’s Hospital Review on July 29, 2011 (written by Molly Gamble).

Medicare and hospitals go hand in hand. Hospital payments account for the greatest share of the federal program’s spending, and Medicare is the largest payor for hospital services, comprising a significant portion of most hospitals’ revenue. As of Oct. 1, though, hospitals will operate under a revised inpatient prospective payment system — one that could put many hospitals at risk.

The proposed changes to IPPS for fiscal year 2012
Imagine if the method of assessing individual taxes changed and the government scrapped its traditional, income-based approach for a model that taxed Americans based upon their personal caliber.

This may sound far-fetched, but healthcare leaders might share a strange yet familiar connection with the scenario — particularly in light of the Centers for Medicare & Medicaid Services’ proposed changes to IPPS. These rules, unveiled in April 2011 for fiscal year 2012 (thus going into effect Oct. 1), contain payment rate changes, coding adjustments, and the quality reporting program which mandates hospitals to report on 55 measures for FY 2012. 

More than 60 percent of hospitals already lose money on Medicare, according to the American Hospital Association. Section 3401 of the Patient Protection and Affordable Care Act detailed across-the-board Medicare payment reductions for hospitals. These cuts are estimated to reduce reimbursements by $155 billion from 2010-2019, a strategy hospitals agreed to accept in 2009 to help fund healthcare reform. While good news for CMS, these additional Medicare cuts could prove devastating to hospitals, particularly when paired with extensive performance-based healthcare delivery reforms, such as value-based purchasing, which is set to begin in Oct. 2012.

Putting IPPS into context
From an academic and legal standpoint, Craig B. Garner, a professor of law at Pepperdine University in Malibu, Calif., says the proposed changes are fascinating. “Throughout its history, Medicare has employed variations of cost-based reimbursement, originally factoring in the actual cost to a provider and then transitioning to a predetermined rate based upon a patient’s particular diagnosis. Soon it may not matter anymore,” says Mr. Garner. “The new regulations are changing a very complex system and steering it in a totally new and equally complicated direction, only this time based on performance.  This will include what people think of a hospital, the patient experience during a hospital stay, and ultimately the reliability of a hospital in its delivery of patient care,” says Mr. Garner.

The complete article can be viewed HERE.

 

How My Career Taught Me To Be a Better Father0

This article first appeared on the PBS affiliated Website This Emotional Life.

“There is no instinct like that of the heart.” Lord George Gordon Byron, British poet

The old adage is true: Timing is everything.  No matter how straight and narrow the road ahead may seem, one must always take into consideration the unexpected, that one, untamable variable that may at any time upset the apple cart and leave us scrambling to regain both composure and apples. For just over 108 months, I was the CEO of a hospital.  For three overlapping months, I was also a father.  The end to one significant stage of my life coincided with the joyous beginning of another.  Timing always rules the day, and, as I have found, it also enjoys irony.

Recently, I made the commitment to pursue certain credentialing and board certifications in health care management, even as my position in this field was in transition.  With a new child at home, a new career to forge, and a new professional distinction in my sights, I dived head first into an unrecognizable abyss, hoping that some yet-to-be-defined synergy (in the form of a very large net) would break my fall. As luck would have it, one of my first assignments was a book by Tom Atchison, Ed.D., which introduced me to “The Synergy Factor.”  As I understand it, this concept is a coalescing of sorts between certain intangible inter-relational ideas and tangible processes within health care administration.  There, in the middle of my matutinal study of the Synergy Factor and health care leadership, my mind started to wander toward my son, and I began to delve into the ways in which I could enhance our relationship in these early stages.

Young children (and many adults as well) exist in the crossroads of the tangible and intangible.  Matters of genetic makeup, demographics, and fiscal stability are common, tangible discussions for many new parents who aspire to provide for their latest family member. More often than not, however, that which is tangible is also hardest to control. The intangible part of parenting, namely the notion of instilling a mutual trust, respect, pride, and joy into the parent-child relationship, also happen to be what Atchison describes as “the source of a sense of purpose and meaningful work as a result of living the mission, values, and vision.” (Atchison, Leadership’s Deeper Dimensions: Building Blocks to Superior Performance, 2005).

Although not necessarily represented in equal proportion, certain factors such as the color of his eyes, the sound of his voice, the bed in which he sleeps and the neighborhood where we reside all share attributes that extend to varying degrees beyond my parental jurisdiction.  But the intangible ways in which I deliver certain messages that speak of and lead to trust, respect, pride, and joy are almost entirely within my control, regardless of those aforementioned tangible realities, as well as any challenges I may face now or in the future as a parent.

Now, as my studies force me to probe deeper into the core of health care management, I constantly find myself reflecting upon my real life lessons learned over the past nine years. No matter what educational background or prior experience a hospital CEO brings to the table, certain on-the-job assignments will necessitate fast, critical thinking.  With such knowledge comes the hope that I myself faced each hospital challenge with a combination of what I learned in school, what I learned from past work-related experiences, and what just felt like the right response. And as I continue to read about tangible and intangible notions in health care management as well as other industry terms and phrases, I begin to realize that I had in fact embraced most of these concepts during my tenure, in deed if not in word as well.

As I reflect upon the past decade with these thinly disguised affirmations from my present studies, I wonder also how I will come to assess my first nine years as a father. At the outset, I am very mindful that this new role differs from the last with respect to the events over which I was ultimately responsible. Now I share the top position with my wife, although to be sure my involvement is shaped by the needs of a newborn and the physical limitations of a father.

Without anything resembling an owner’s manual to follow as I try to build connections with my son while navigating the uncharted waters of new fatherhood, I realize that my instincts will be my second greatest ally, preceded only by those of my wife.  Thanks to the recent validation of these very instincts in hospital management, I am mindful that timing is still everything, and not all variables can be controlled.  Some must be dealt with as they emerge. Certain concepts that previously had no words in health care management may also be unknown terms to me in parenting.  For now, however, I can reassure myself by embracing both the tangible and intangible, and perhaps borrow some of these newly acquired definitions from health care to light my way.  After all, my goal is to build a solid foundation with which to give me footing among these intangibles in preparation for a lifelong journey with my son. In many ways, this is not so different from the way in which I approached the running of a hospital.  This time, however, the stakes are more profound, not to mention precious.

 

Health Care Reform in California: What Does It Mean for Attorneys and Clients?0

The following article appeared in the July 11, 2011 Daily Journal.

At the end of June, the 6th U.S. Circuit Court of Appeals weighed in on the health care reform debate, focusing in particular on the constitutionality of the health insurance mandate embedded within the Patient Protection and Affordable Care Act (PPACA). This was the first mid-level Federal Court to opine on the subject, casting the decision as an important benchmark as PPACA inches closer toward intervention by the U.S. Supreme Court.

The 6th Circuit concluded that the insurance mandate, sometimes referred to as the minimum coverage provision, is constitutional and within congressional authority under the Commerce Clause. However, this most recent ruling is not alone in its attempt to define the future of American health care.  Other noteworthy if disparate decisions also on point include: an opinion last December from a District Court in Virginia striking the same (insurance mandate) provision, but confirming at least indirectly the overall constitutionality of PPACA; and a ruling in January from a District Court in Florida, declaring PPACA unconstitutional in its entirety.

These are exciting times for medical professionals, including health care practitioners and other attorneys who confront issues of contract, real estate, tax, employment, tort, bankruptcy or antitrust law in their practice.  But what effect does the fluidity of the modern American health care structure have on our clients as PPACA continues to work through its growing pains? It is often easy to overlook important, client-centric issues when daily media headlines spew prognostications of unprecedented historical importance.  Esoteric as they may appear on the surface, however, these high profile discussions offer a wealth of relevant information for attorneys and their clients, even if such wisdom is hidden beneath a cloak of ambiguity as thick as the pages of reform legislation itself.

By setting their sights on two of the basic concepts contained within PPACA, health care practitioners are better suited to cut through the controversy and rhetoric, and focus instead on the needs of their clients.

The first issue impacts nearly everyone in the field, including attorneys who may represent individuals or businesses:

To meet PPACA’s requirements in 2014, individuals have the option to: enroll in a government program such as Medicare, Medicaid (California’s version of Medicaid is “Medi-Cal”), or TRICARE; participate in qualified insurance programs offered through employment; or purchase a qualified insurance policy, either through a series of state exchanges that are scheduled to begin in or around 2014 or directly from an insurer. To be “qualified” a plan must cover certain “essential health benefits,” at least up to a defined percentage of actuarial value.

Starting in 2014, failure to obtain or maintain preexisting qualifying health care coverage will result in a penalty of $95 or 1 percent of the individual’s income, whichever is greater. In 2016, this penalty increases to $695 or 2 percent of the individual’s income. There are companion penalties for families (capped at three times the per-person flat amount) and dependent children (half of the per-person flat amount).

In the end, the debate over whether or not the Commerce Clause was designed to extend this far will be of little value to individual clients who seek professional advice in understanding how much they may be required to pay or have deducted from income tax filings. This may impact the tax returns of approximately 140 million clients, as well as 15-20 million others who previously did not file, a sizeable client base for any law firm.

While PPACA will require individuals to obtain health care insurance, businesses are under no obligation to offer coverage to employees. Instead, larger employers constituting 50 or more full-time employees will face a $2,000 per employee penalty (which does not apply for the first 30 full-time employees) in the event these employees receive federal subsidies for health insurance. Furthermore, if businesses offer health care plans that are too expensive – known as “Cadillac Plans” – they will face a 40 percent tax imposed in 2018.  On the other hand, small businesses stand to gain generous new tax credits designed to encourage the implementation of qualified health insurance plans for their employees.

As the ongoing debates continue to unfold, both large and small businesses would do well to seek legal consultation in balancing the competing variables before making decisions pertaining to coverage. In deciding whether to offer a health care plan or pay the $2,000 per full-time employee fine, proper advice may necessitate expertise in tax, employment, and/or contract law, in addition to a certain amount of health care acumen. And while not an issue today, practitioners should be aware that they may face scrutiny under the California Rules of Professional Conduct, and Rule 3-310 in particular, for representing both individuals and businesses (small and large) in deciding whether or not to obtain or offer health care insurance.  These are just a few of the complexities upon which attorneys will be called for assistance as health care reform flexes its newfound muscles.

The second issue involves the possible future of health care reimbursements, and Medicare in particular. In April 2011, the Centers for Medicare & Medicaid Services (CMS) published regulations designed to change the structure of hospital reimbursements. Authorized within PPACA, CMS will start paying hospitals Medicare “bonuses” based upon overall performance, adherence to quality measures, and patient satisfaction.  This hospital value-based purchasing program is another step toward shifting the focus of reimbursement infrastructure from the cost of services during a hospital stay to improvements in patient health and performance during a hospital stay.

With the laudable intertwined goals of improving patient care nationwide while saving money for the Medicare system, beginning in October 2012 hospitals will be entitled to share bonus money from an $850 million fund based upon their scores in these newly defined measures. The following year, hospitals will face a 1 percent [reduction] overall on Medicare payments under the inpatient prospective payment system, as these funds will be redirected toward the aforementioned performance bonuses. By 2015, hospitals with a track record of poor performance will not only face exclusion from the bonus pool, they will also face additional cuts in reimbursement.

The maturation process of American health care reform has a long way to go, with each new stage bringing with it a complex set of issues. At each turn, attorneys will be called upon to assist clients in understanding and incorporating structural, legal, and ethical changes. If this alone was not enough of a challenge to our profession, we must also address the inherent conflicts between the desire to make health care better and less expensive and the knowledge that to do so may compromise the livelihood of a hospital, doctor, or medical facility.

As sweeping as the far-reaching implications of PPACA may sound, attorneys must be ever mindful of their clients’ needs as they navigate what is sure to be a future filled with shifting terrain. Regardless of health care reform’s political ramifications, the fundamental concepts behind the upcoming reorganization of the reimbursement paradigm are epic. In many ways, replacing cost-based reimbursement with performance variables appears just as drastic as eliminating income as a factor for calculating individual taxes in favor of implementing a series of assessments designed to quantify the benefit an individual may or may not confer upon society. To truly provide for our clients in upcoming uncertain times, we must be able to relate to the ramifications not only of today’s health care structure, but those that tomorrow has in store for us as a nation.

 

Breaking Language Barriers in Health Care1

This article first appeared in California Healthcare News.

“Most of the fundamental ideas of science are essentially simple, and may, as a rule, be expressed in a language comprehensible to everyone.” – Albert Einstein

Imagine finding yourself in a hospital, only to discover that you no longer have a mouth or ears.  You cannot explain your symptoms, identify next of kin, or describe your medical history, nor can you understand the doctor’s diagnosis, instructions, or prognosis.  For the growing number of patients in Emergency Rooms across the United States who arrive unable to communicate effectively in English, this is no dream, but a frightening reality.

In an emergency time is short, and swift, accurate communication is essential for establishing a foundation from which the doctor can attempt a diagnosis. According to a survey by the Health Care Interpreter Network, more than 70 percent of American health care providers admit that language barriers regularly compromise patients’ understanding of their disease, increase the risk of complications, and make it difficult for patients to communicate effectively with their doctors, often leading to costly delays in treatment.  Furthermore, in some cases the stigma and frustration attached to having limited English proficiency (LEP) is enough to discourage people from seeking treatment altogether, while those who are able to overcome their fear or embarrassment run the risk of misunderstanding the physician’s instructions, especially when it comes to home follow-up care and the taking of medication.

Many of the facts surrounding issues of language in a hospital setting are surprising.  Statistics from the United States Census show that nearly one in five legal American residents speaks a language other than English at home, adding up to nearly 60 million people nationwide, and that number continues to rise with each passing year.  However, this growth is no longer limited to large urban environments, as many of today’s immigrants are finding pockets among smaller towns in states not often associated with immigrants, such as Arkansas, Kansas, Colorado, Kentucky and Tennessee, leaving local hospitals scrambling to find the appropriate means to deal with newly presented language barriers.

Furthermore, Spanish is by no means the only issue.  Though by far the most common language encountered, it is joined by such disparate tongues as Chinese, Russian, Arabic, Vietnamese, Portuguese, Hindi, Japanese, Korean, and American Sign Language, to name a few, making it nearly impossible for most hospitals to cover the needs of their entire patient-base.  Even in situations where a low-level translator is available, errors in diagnosis may occur as a result of “false friends.” For example, in Spanish the word “constipado” refers to a respiratory rather than a digestive condition, meaning “unable to breathe.”  Similarly, “intoxicado” means simply “dizzy,” without regard for reason why.

While such communicative chaos is certainly bad for patients, it also places burdens on hospitals, as the cost of the resultant unnecessary tests, longer treatment times, decreased provider efficiency, and repeat visits are often thrust onto the shoulders of the facility.  Under Title VI of the Civil Rights Act of 1964, hospitals receiving Medicare or Medicaid are obligated to provide free translation services to patients, though the government provides little or no reimbursement. Neither Medicare nor the vast majority of private health insurers covers issues of interpretation, though both deal in high volumes of LEP beneficiaries.  Depending on the language involved, medical translation services can run as high as $400 per hour.

Recognizing the effect on both patient and facility, many hospitals have begun to address this burgeoning issue with the attention it deserves.  With the added incentive put forth by the Joint Commission accreditation standards begun in 2008 and set to take effect in January 2011, today’s medical facilities have started to focus more keenly on their commitment to supporting numerous languages and providing new solutions to the problems caused by the inability to communicate in a health care-related setting.  For example, many larger hospitals now boast a combination of in-house and freelance interpreters to cover the needs of their community, as well as hiring more bilingual employees in both medical and non-medical capacities.  Recent years have also shown greater emphasis on training in-house staff to work in conjunction with interpreters and an increase in overall cultural awareness. Though expensive, phone interpretation is another way in which hospitals can effectively procure important information in an emergency.

Since the aftermath of Hurricane Andrew in 1992, picture boards have increased dramatically in popularity among hospitals with high numbers of LEP patients.  These laminated panels provide simple icons depicting health issues such as cuts, burns, trouble breathing and chest pain, as well as images of body parts to show where the patient is affected.  Though limited in scope and detail, the boards are an effective way to give the physician a quick overview of the situation while an interpreter is being located, and they work equally well for those patients who are deaf, mute, or unable to speak due to a medical condition or as a result of a breathing tube or apparatus.

Though only an initial step, the edict put forth by the Joint Commission serves to publicize the need for more effective translation services in America’s hospitals while adding incentive for health care facilities who do not wish to lose Medicare and Medicaid funding due to non-compliance.  Bettering doctor-patient communication in the future is essential to the vitality of our health care system, as it is a proven and effective way to cut costs, improve care, and save lives.

The Controversial Independent Payment Advisory Board Takes Shape0

This month the fifteen members of the Independent Payment Advisory Board (IPAB) will convene for the purpose of making recommendations to reduce Medicare expenses, provided Medicare’s spending exceeds a predetermined limit.

Before the Patient Protection and Affordable Care Act (PPACA), the Medicare Payment Advisory Commission (MedPAC) recommendations, in addition to an act of Congress, were necessary to effectuate changes in Medicare reimbursement. MedPAC is an independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33). MedPAC must advise Congress on issues affecting the nation’s Medicare program, and it must also analyze access to care, quality of care, and other issues affecting Medicare.

MedPAC issues two reports each year (March and June).  These report include key recommendations by the Commission to Congress.  MedPAC also advises Congress through various comments on other reports and proposed regulations issued by the Secretary of the Department of Health and Human Services, and MedPAC provides testimony and briefings for the legislative branch.  MedPAC’s June 2011 report can be found here.

Under PPACA, Congress only has the authority to overrule the decisions of the unelected IPAB, and absent such affirmative steps by Congress, the Secretary of Health and Human Services must implement IPAB recommendations. IPAB is scheduled to implement changes in 2015, with a first report due by July 2014.

IPAB’s historical origins date back more than a decade. In 2000 and 2001 Senators Breaux and Frist championed reform proposals designed in part to create separate federal agencies under the Centers for Medicare & Medicaid Services (CMS) to oversee certain parts of the Medicare program. There was also some interest in establishing a Medicare Board to oversee and coordinate traditional Medicare and private plans.

Senator Tom Daschle  also supported a Federal Health Board, similar in design to the Federal Reserve Board, to oversee health care in the public and private markets. In mid-2009, Senator Rockefeller introduced the Medicare Payment Advisory Commission Reform Act of 2009. Senator Rockefeller’s proposed legislation would have modified MedPAC from its present state of 15 advisory members to an agency within the executive branch consisting of 11 members, including expanded authority over coverage and payment issues.

IPAB action is required only when Medicare spending exceeds certain thresholds. The Chief Actuary of CMS is responsible for determining when Medicare exceeds its anticipated growth, and thereafter IPAB must determine the appropriate reductions in Medicare spending. Under PPACA, IPAB shall not make decisions that “include any recommendation to ration health care, raise revenues or Medicare beneficiary premiums under section 1818, 1818A, or 1839, increase Medicare beneficiary cost sharing (including deductibles, coinsurance, and co-payments), or otherwise restrict benefits or modify eligibility criteria.”

In November 2010 the Congressional Research Service provided the following explanation:

If the Chief Actuary finds that the growth rate does not exceed the targeted growth rate, the process for the year ends. If the Chief Actuary determines that the growth rate exceeds the target growth rate for any DY [determination year], the Chief Actuary is required to establish an applicable savings target for the IY [implementation year]. The applicable savings target is an amount equal to the product of the total projected Medicare expenditures in the PY  [proposal year] times the applicable percent. The applicable percent is defined as the lesser of either the projected excess for the IY (the amount by which Medicare spending is forecast to exceed the targeted growth in spending expressed as a percent of total Medicare expenditures) or the percent as specified in the statute (0.5% in IY 2015; 1.0% in IY 2016; 1.25% in IY 2017; and 1.5% in 2018 and any subsequent IY). In either event, the percent is converted to a dollar amount by which Medicare program expenditures must be reduced.

Although PPACA precludes IPAB from rationing health care directly, critics fear the board’s decisions may have the same effect.  IPAB has been compared to the National Institute for Health and Clinical Excellence (NICE), the United Kingdom’s mechanism to set quality standards, make recommendations on medicines, treatments and procedures, and cut costs. In March critics of NICE in the UK alleged that 20,000 people died after the agency rejected cancer medications due to cost-effectiveness. The White House disagrees with such a comparison and instead offers the following information on www.WhiteHouse.gov:

PAB is a backstop – it would only take effect if Medicare costs grow too fast.  We’re already implementing a series of reforms that will improve the quality of care and reduce costs. In fact, according to Congressional Budget Office projections, Medicare spending won’t hit the targets that would cause IPAB’s recommendations to take effect in the next decade.

The IPAB has a very specific purpose, although its authority to accomplish such may be subject to interpretation by critics and proponents alike. Absent modification or repeal of PPACA, IPAB will most likely have an opportunity to impact Medicare, and only time will determine IPAB’s success or failure.

 

Our Fear-Driven Regulatory Realm0

The following article first appeared January 27, 2011 in the publication Payers and Providers.

Our Fear-Driven Regulatory Realm: One Event, Not Day-to-Day Reality, Pushed SB 1953

As the CEO of a small Los Angeles County hospital who has dealt in the past with the Office of Statewide Health Planning and Development, I read Jim Lott’s recent opinion “Is OSHPD an Obstacle to Growth?” with great interest.  Mr. Lott’s astute recap of both the potential behind SB 1953’s initial design and the corresponding shortcomings in its deployment was in my opinion insightful.

However, to cast the blame entirely on OSHPD is not necessarily fair, especially when it comes to state-mandated seismic safety standards.  In marshalling all California hospitals in the direction of SB 1953, OSHPD has been charged with a Herculean task, which has been compounded by our current economic climate. With such responsibility thrust upon the shoulders of an underfunded, understaffed department, efficiency was certainly never a priority in the minds of its makers. Furthermore, as important as this role may be, upon reflection it stems in large part from the fear generated by a high profile tragedy and the arguable overreaction of state policymakers and popular media.  Too often after these events the course of health care shifts its aim away from the big picture to dwell on anomaly, often to the detriment of both patients and providers.

To be certain, the isolated events that capture our attention are often devastating, tearing apart families, communities, even cities.  In early January an angry, disturbed young man killed six with his gun. Some of the victims were high profile and others were tragically young.  As the fallout from this shooting captured the nation’s spotlight, significant focus centered on episodes of unidentified bipolar disorder and schizophrenia.  Mental health experts trumpet the warning signs of illness leading to such a violent event much like Californians speak of “The Big One,” even though less than 0.004% of the U.S. population is likely to die from firearms each year.  When this occurs, the spotlight is shifted away from more prevalent threats such as diabetes, obesity, and heart disease, though the after-effects on the families of those who die from these understated killers are no less devastating.

Similarly, when fear of catastrophe sets the tone for policy, funding is often funneled away from its most deserving targets. The idea for SB 1953 came about after a 6.7 magnitude earthquake in Los Angeles County, California killed 72 people in January, 1994.  Seventeen years later, hospitals across California are spending their part of the estimated 90 to 120 billion dollars to ensure they meet the seismic safety requirements mandated by the state legislature, regardless of their day-to-day fiscal health.  While the Northridge Earthquake unquestionably caused tremendous damage to Southern California, the proposed price tag when broken down runs about $1.7 billion per fatality.

As an administrator, it is confusing to me that America’s health care is so often dictated by the after-effects of an aberrant, high profile tragedy, while more subtle yet more prolific killers go largely unpublicized as their cures remain underfunded and their victims die without fanfare, or essential, ear-marked funds are rerouted to assuage tomorrow’s fears. Seismic compatibility is a goal worth attaining, but in these troubled economic times as hospitals both large and small struggle to keep their doors open to a dependent public, it certainly does not hurt to understand the origins of this expensive overhaul, and question whether these funds would be better spent on preserving the quotidian rather than planning for a possible catastrophe.  By 2015 all functioning California hospitals should be prepared for the Great Shock, but how many will remain to be left standing, regardless of the whims of Mother Nature?

 

The Joint Commission Center for Transforming Healthcare Targets Wrong Site Surgery0

Last week the Joint Commission Center for Transforming Healthcare released detailed solutions for health care providers in reducing the risk of wrong site surgery.

By using certain methods such as Lean Six Sigma (originally a set of practices designed to eliminate defects in the manufacturing process, it has recently been applied in other areas such as health care)  and change management to identify the causes of wrong site surgery, the institutions cooperating with the Joint Commission Center identified concerns with scheduling, ineffective communication. and operating room distractions.

Furthermore, the “Time Out” process (occurring prior to the incision, the surgeon calls a “Time Out” so that every member of the surgical team can pause to verify the correct operative site) was only successful when it included all key people in the operating room. The Joint Commission Center also noted:

By reinforcing quality and measurement, emphasizing a culture of safety, strengthening knowledge about wrong site surgery, and improving consistency in surgical processes, the eight participating health care organizations and the Center found that opportunities for errors or defects could be reduced. For example, addressing documentation and verification issues in the pre-op/holding areas decreased defective cases from a baseline of 52 percent to 19 percent. Defects are the causes of and risks for wrong site surgery. In turn, the incidence of cases containing more than one defect decreased 72 percent. The focus on eliminating defects is important because a single operative case has multiple opportunities for defects. When there are multiple defects in a single case, it can further increase the risk of an error reaching the patient. Additionally, it was found that defective cases occurred more frequently when more than one procedure was performed.

Additional information can be found at the Joint Commission Online.

The American Medical Association on Certification and Licensing0

According to the Association of American Medical Colleges (AAMC), the medical profession faces a deficit of about 60,000 physicians by 2015. While the AAMC and American Association of Colleges of Osteopathic Medicine (AACOM) continue to increase the number of physician candidates accepted into their programs, the American Medical Association recently provided an added boost. At its annual meeting, the AMA discussed the unnecessary time and money physicians spend meeting certain medical licensing and board certification requirements.

In response, the AMA adopted six policies focusing on specialty certification and licensure, some of which included:

According to Gregory Threatte, MD, an alternate delegate for the Medical Society of the State of New York and an anatomic/clinical pathologist: “It is a critical issue to a lot of physicians. There is widespread concern about these multiple certifications and licensure examinations that are starting to chew up more and more expense.”  As another example, board certification in radiology requires passing 11 exams, in addition to exams every 10 years to maintain the certification.

Additional information about the AMA’s 2011 Meeting of the House of Delegates can be found here.

 

Lost Hospital: Huron Hospital, East Cleveland, Ohio0

The 20-bed Lake Street Hospital in Cleveland, later known as the Cleveland Homeopathic Hospital, opened in 1856. In the early 1870s, physicians from the Homeopathic Hospital purchased the Humiston Institute building for $35,000, and subsequently opened the Cleveland Protestant Homeopathic Hospital or Huron Road Hospital. Also known as the Cleveland Homeopathic Hospital College, this 50-bed institution soon became a pillar in Cleveland’s health care system.

In 1884 the Cleveland Training School for Nurses opened. This accomplishment, however, was clouded by 32 years of disputes between the hospital and the homeopaths, including a nursing strike in 1908 as well as litigation designed to keep allopathic doctors out of the hospital. Closed at times for repairs and other times due to these disputes, in 1924 the hospital was sold and renamed Meridia Huron Hospital.

In 1935 the hospital moved to part of the former John D. Rockefeller estate in East Cleveland. Over the years, the hospital flourished and in 1984 became the original institution of the Meridia Health System (which merged in 1997 with the Cleveland Clinic Foundation). Huron Hospital’s legacy will end in 2011 due to finances.

In June 2011 the Cleveland Clinic announced Huron Hospital would close and cease treating the patients in East Cleveland. East Cleveland’s Mayor Gary Norton tried to stop the closure, hoping to prevent what just about any big-city mayor fears when a hospital closes.  Norton explained: “The community is often left with a vacant building that grows high weeds, has windows broken out and a source of revenue that is just lost.  But by working together we wanted to show that if we work in a new way, doing something different and talking instead of pointing fingers at each other, that we might be able to accomplish something that mitigates the loss.”

When Huron Hospital closes, the Cleveland Clinic contends it will find another viable use for the building, or instead pay the estimated $10-$15 million cost to demolish and clear the structure.  This transition, however, has placed East Cleveland and Cleveland at odds as Cleveland leaders argue the hospital’s closure will compromise the City’s emergency services network.

EMS Commissioner Edward Eckhart noted: “The result of the loss of trauma service at Huron and the resulting closure of Huron has resulted in increased EMS response times to all 911 calls, to every neighborhood in the City of Cleveland; it’s resulted in fire first responder units being tied up in excess of 30 to 45 minutes throughout the city while they are waiting for EMS ambulances to arrive to transport patients.”

Robert Triozzi of the Cleveland Clinic has tried to spin the hospital’s closure as a difficult but necessary decision that will not impact health care in the community:

“We recently made the difficult decision to close Huron Hospital within 90 days. Outpatient care will continue to be provided at Huron Hospital until the new Cleveland Clinic Huron Community Health Center opens on October 3, 2011. In light of this decision, it’s important for you to know that our commitment to East Cleveland and the surrounding communities remains strong. [¶] We did not come to this decision lightly. Over the years we have experienced a steady decline in patients using Huron Hospital, a rapidly shrinking population, costly maintenance of the hospital’s aging facilities, as well as a dramatic shift in the way healthcare is delivered.”

When the hospital closes in October 2011, the new Cleveland Clinic Huron Community Health Center will attempt to provide the necessary health care in East Cleveland. Even though the new clinic is expected to provide state-of-the-art outpatient care (including primary coverage, care for women and children, and services focusing on mental health), the community will still lose a hospital and its 155 years of history.

 

PBS’s ‘This Emotional Life’: Medicine By the Numbers

Lewis Carroll wrote: “If you want to inspire confidence, give plenty of statistics. It does not matter that they should be accurate, or even intelligible, as long as there is enough of them.”

When people are first told that a loved one is in the hospital, they want answers. Straight answers. And they want them fast.

But oftentimes in today’s medical centers, what patients and family members alike are met with is numbers: Hypotheticals, probabilities and percentages. When combined with complex medical jargon, this can quickly lead to confusion and uncertainty, as those involved must make sense of the stats before they can understand the state of the patient’s condition. Without the proper frame of reference, this type of information can quickly exacerbate fears and increase emotional distress. Rather than serve as beacons to shed light on a patient’s chances, these figures quickly become barriers to the truth. For many of us, the numbers are to be feared, not followed.

Still, whether we like it or not, playing the percentages is a medical necessity. In the modern age, health care is all about the bottom line. As technology advances and life expectancy increases, today’s treatment options become more and more focused on the probabilities of success or failure. From prenatal care to geriatric services, every patient ultimately wants to know one thing: “Where do I stand?” More and more, the answer is delivered as a number, culled from experience, testing, and appropriate clinical research trials. This often leaves the physician to mediate between patient and procedure, as he or she attempts to present new information in such a way that those involved can both understand and take comfort from that most dispassionate of messengers, the statistic.

The numbers themselves are not to be blamed. At the risk of making modern health care sound like a sports bar in Las Vegas, the purpose of statistics in a medical environment is to give the facts about a patient’s condition in black and white, which, if not done humanely, can seem lacking in compassion. The key to recognizing the value of such numbers is to use them as guidelines, not ultimatums.

Properly used, statistics perform a dual function: When correctly interpreted and explained, these numbers can act as a security blanket, breaking down frightening uncertainties into hard facts in which patients can wrap themselves during a time of emotional upheaval, while also providing a solid understanding of treatment options and outlooks. From a doctor’s perspective, they stand as a buffer, protecting the physician from being forced into the unrealistic role of savior, no matter what the condition. In their way, percentages help to reinforce the idea that nature, and not the doctor, will ultimately make the final call as to a patient’s future. Such impartiality goes a long way toward strengthening the doctor-patient relationship, especially when the prognosis is not as good as a patient might have expected.

Numbers can be persuasive to those patients faced with making important yet difficult lifestyle changes or deciding upon end-of-life treatments. For patients diagnosed with serious illnesses and their families, much of today’s medical data provides hope. For example, according to the information available at the end of 2009, life expectancy in the United States reached an all-time high in 2007 — 77.9 years (75.3 years for men and 80.4 years for women). Between 2006 and 2007, rates dropped for nearly half of the leading causes of death in the United States (cancer, heart disease, stroke, hypertension, accidents, diabetes, homicides and pneumonia), reaching a new low of about 0.76 percent of the population (760.3 deaths per 100,000 people). That is approximately one half the rate from 1947. Once fatal illnesses are slowly being reclassified, provided the patient heeds the warnings found among the numbers and takes the appropriate steps to live in a healthier manner.

On the other end of life’s spectrum, many newly pregnant couples become surprisingly imaginative upon first hearing their good news and spend much time contemplating the worst. To calm the parents’ nerves (and to protect the doctor’s interests), it is now standard practice to administer a series of tests to assess the baby’s health throughout development. Then end result of most of these tests comes back in numbers. Statistics again.

Without debating the ethics and morality of abortion, which is not a doctor’s role, many of these tests seek to ascertain the health of the fetus and predict the odds of certain birth defects such as Down syndrome, trisomy 18, or trisomy 13. The number of things for a pregnant couple to worry about can be staggering, yet doctors are often obligated to advise them of the chances in advance. For example, in North America, 1 in 260 females carry the chromosome for Fragile X (also known as “Martin-Bell”) syndrome, a genetic disorder that results in an array of physical and mental limitations, ranging from severe to mild in manifestation. Likewise, 1 in 149 Ashkenazi Jewish individuals carry the gene for Nemaline Myopathy, a neuromuscular disorder that causes muscle weakness of varying severity. In its most potent form, Nemaline Myopathy results in death after just a few years. By incorporating these tests with such relevant factors as the age and overall health of the mother and the genetic background of each parent, doctors can provide a statistical model on which to gauge the probability of the baby’s being born to normal health. This can provide parents with peace of mind if the chances of defects are low, or the opportunity to prepare themselves or consider their options if the outlook is not favorable.

At least one reason behind the surge in statistical diagnosis is the continued rise in medical malpractice claims. Having been forced into the role of omniscient healer as a result of advances in diagnostic testing, doctors must now use this same technology to cover themselves in the event of a statistical improbability. A recent study by the American Medical Association concluded that “defensive medicine” (defined as medicine relying upon diagnostic and other therapeutic measures to safeguard against malpractice claims first, and the health of the patient second) increase health care costs by as much as $150 billion each year. To be sure, throwing the title of statistician into a doctor’s medical bag of magic tricks does not help to further the doctor-patient relationship.

There is no numeric substitute for direct and clear communication between a doctor and patient. That said, making sense of medical statistics can go a long way in helping a patient understand diagnosis, prognosis and treatment. If you or a loved one has been diagnosed with a potentially life-threatening illness, your decisions about treatment can often be linked to “quality of life” concerns. No matter what age, patients want answers to certain questions, often combined with supporting statistics, such as:

  • How will this disease affect my life on a day-to-day basis
  • Is this disease terminal, or if left untreated, will it become terminal?
  • How will the treatment affect my life on a day-to-day basis?
  • How will the disease, treated and/or untreated, alter my life expectancy compared to my anticipated decline in health as I age?

It is important to remember that statistics are numbers, plain and simple. While numbers may not lie, they have no bedside manner and can be interpreted in a variety of methods and made to suit many arguments. The best way to know where you or your loved one stands is to discuss your situation clearly and openly with your doctor, taking into consideration the big picture as well as the percentages.

This Emotional Life is a two-year campaign to foster awareness, connections and solutions around emotional wellness. Join our community at www.pbs.org/thisemotionallife.