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Healthcare is drowning in administrative glut

quicksand

Marion Mass, M.D., wrote a piece  for The Philadelphia Inquirer headlined “A doctor’s perspective: Who stands for patients in the healthcare debate?” Among her observations:

“Take a look at the top lobbyist groups in America. Four are health-care related: Big insurance, Big Pharma, the American Hospital Association and the American Medical Association.

“The result of this lobbying is a phenomenon that can be summed up in two words: administrative glut.

“Since 1970, the number of physicians practicing in America has grown by roughly 200 percent. By contrast, the percentage growth of administrators in the same time period is over 3,000 percent. Healthcare spending per capita has grown by 2,300 percent over the same time period. ”

“The American people are the victims of a {healthcare} system so complex that even many practicing physicians have a hard time unraveling it. But they are certain that their patients’ needs are suffering. Your physician, the one delivering or caring for your children, the one who guides you through your twilight years, has little voice and less confidence in this establishment, mirroring the feelings of frustrated Americans

“There is hope.

“Dozens of grassroots physician groups are working for real reform. We are aligned together and actively collaborating, to find real solutions to heal our sick system.  United, we have a stronger voice to advocate for our patients. We see your suffering. It’s personal for us, because medicine is personal. You learn that the first time you interview a patient and lay your hands on them for examination.

“We believe reducing administrative glut and creating more choices of coverage are the two main components to increase quality access to care and reduce cost for all. The Health Rosetta Principles, formulated as a collaborative effort among entrepreneurs and visionaries in the healthcare space, covers the basic tenants of our proposed changes. A  specific, patient-centric representative plan has been developed by  the Docs4Patient Care Foundation.”

To read her entire essay, please hit this link.

 


Feds cracking down on hospitals over infections

bacteria

By JORDAN RAU

For Kaiser Health News

The federal government has cut payments to 769 hospitals with high rates of patient injuries, for the first time counting the spread of antibiotic-resistant germs in assessing penalties.

The punishments come in the third year of Medicare penalties for hospitals with patients most frequently suffering from potentially avoidable complications, including various types of infections, blood clots, bed sores and falls. This year the government also examined the prevalence of two types of bacteria impervious to drugs.

Based on rates of all these complications, the hospitals identified by federal officials this week will lose 1 percent of all Medicare payments for a year — with that time frame beginning this past October.  While the government did not release the dollar amount of the penalties, they will exceed a million dollars for many larger hospitals. In total, hospitals will lose about $430 million, 18 percent more than they lost last year, according to an estimate from the Association of American Medical Colleges.

The reductions apply not only to patient stays but also will reduce the amount of money hospitals get to teach medical residents and care for low-income people.

Forty percent of the hospitals penalized this year escaped punishment in the first two years of the program, a Kaiser Health News analysis shows. Those 306 hospitals include the University of Miami Hospital in Florida, Cambridge Health Alliance in Massachusetts, the University of Michigan Health System in Ann Arbor and Mount Sinai Hospital in New York City.

Nationally, hospital-acquired conditions declined by 21 percent between 2010 and 2015, according to the federal Agency for Healthcare Research and Quality, or AHRQ. The biggest reductions were for bad reactions to medicines, catheter infections and post-surgical blood clots.

Still, hospital harm remains a threat. AHRQ estimates there were 3.8 million hospital injuries last year, which translates to 115 injuries during every 1,000 patient hospital stays during that period.

Each year, at least 2 million people become infected with bacteria that are resistant to antibiotics, including nearly a quarter million cases in hospitals. The Centers for Disease Control and Prevention estimates 23,000 people die from them.

Infection experts fear that soon patients may face new strains of germs that are resistant to all existing antibiotics. Between 20 and 50 percent of all antibiotics prescribed in hospitals are either not needed or inappropriate, studies have found. Their proliferation — inside the hospital, in doctor’s prescriptions and in farm animals sold for food — have hastened new strains of bacteria that are resistant to many drugs.

One resistant bacteria that Medicare included into its formula for determining financial penalties for hospitals is methicillin-resistant Staphylococcus aureus, or MRSA, which can cause pneumonia and bloodstream and skin infections. MRSA is prevalent outside of hospitals and sometimes people with it show no signs of disease. But these people can bring the germ into a hospital, where it can be spread by healthcare providers and be especially dangerous for older or sick patients whose immune system cannot fight the infection.

Hospitals have had some success in reducing MRSA infections, which dropped by 13 percent between 2011 and 2014, according to the CDC. AHRQ estimates there were 6,300 cases in hospitals last year.

The second bacteria measured for the penalties is Clostridium difficile, known as C. diff, a germ that can multiply in the gut and colon when patients take some antibiotics to kill off other germs. It can also spread through contaminated surfaces or hands.

While it can be treated by antibiotics, C. diff can also become so serious that some patients need to have part of their intestines surgically removed. C. diff can cause diarrhea and can be deadly for the elderly and other vulnerable patients.

C. diff has challenged infection control efforts. While hospital infections dropped 8 percent from 2008 to 2014, there was a “significant increase” in C. diff that final year, the CDC says. AHRQ estimated there were 100,000 hospital cases last year.

“The reality is we don’t know how to prevent all these infections,” said  Louise Dembry, M.D., a professor at the Yale School of Medicine and president of the Society for Healthcare Epidemiology of America.

The Hospital-Acquired Condition Reduction Program also factors in rates of infections from hysterectomies, colon surgeries, urinary tract catheters and central line tubs. Those infections carry the most weight in determining penalties, but the formula also takes into account the frequency of bed sores, hip fractures, blood clots and four other complications.

Specialized hospitals, such as those that treat psychiatric patients, veterans and children, are exempted from the penalties, as are hospitals with the “critical access” designation for being the only provider in an area. Of the remaining hospitals, the Affordable Care Act requires that Medicare penalize the 25 percent that perform the worst on these measures, even if they have reduced infection rates from previous years.

That inflexible quota is one objection the hospital industry has with the penalties. In addition, many hospitals complain that they are penalized because of their vigilance in detecting infections, even ones that do not cause any symptoms in patients. Academic medical centers in particular have been frequently punished.

“The HAC penalty payment program is regarded as rather arbitrary, so other than people getting upset when they incur a penalty, it is not in and of itself changing behavior,” said Nancy Foster, vice president for quality and patient safety at the American Hospital Association.

Federal records show that 347 hospitals penalized last year will not have payments reduced because their performance was better than others. Those include Harbor-UCLA Medical Center in Los Angeles, the Johns Hopkins Hospital in Baltimore and the University of Tennessee Medical Center in Knoxville.

Over the lifetime of the penalty program, 241 hospitals have been punished in all three years, including the Cleveland Clinic; Intermountain Medical Center in Murray, Utah; Ronald Reagan UCLA Medical Center in Los Angeles; Grady Memorial Hospital in Atlanta; Northwestern Memorial Hospital in Chicago; and Brigham & Women’s Hospital in Boston.

The penalties come as the Centers for Medicare & Medicaid Services also launches new requirements for hospitals to ensure that the use of antibiotics is limited to cases where they are necessary and be circumspect in determining which of the drugs are most likely to work for a given infection. Hospitals will have to establish these antibiotic stewardship programs as a condition of receiving Medicare funding under a regulation the government drafted last summer.

Lisa McGiffert, who directs Consumers Union’s Safe Patient Project, said that as a result of Medicare’s penalties and other efforts, “more hospitals are thinking more about appropriate use of antibiotics.” However, she said, “I think most hospitals do not have effective antibiotic stewardship programs yet.”

 


10 things about CMS bundled-payment rule

 

Becker’s Hospital Review has done a handy 10 things to know about CMS’s final rule on a mandatory bundled-payment program for coronary-artery-bypass surgery and its expansion of the existing Comprehensive Care for Joint Replacement program. To read whole article, please hit this link.

Here they are, stripped down:

1. “Under the final rule, acute care hospitals in certain markets will be accountable for the cost and quality of care provided to heart attack, coronary bypass and surgical hip and femur fracture patients beginning with hospitalization and extending 90 days after discharge.”

2. “The rule expands the existing CJR model to include additional surgical treatments for hip and femur fractures….”

3. “Hospitals will receive retrospective episode-based payments under the new bundles. Hospitals that spend less than the target price for the episode of care while meeting or exceeding quality standards keep the savings achieved. A hospital is required to repay Medicare if the costs exceed the target price.”

4. “The final rule includes a cardiac rehabilitation payment model, which will test whether a payment incentive can increase the utilization of cardiac rehabilitative services….”

5. ”The heart attack and coronary bypass bundled payment model will be mandatory for hospitals in 98 metropolitan statistical areas….”

6. ”About 860 hospitals will participate in the hip- and femur- fracture bundles, which will be tested in the 67 MSAs already selected for the CJR model.”

7. ”The cardiac rehabilitation payment model will be implemented in 90 MSAs, 45 of which were not selected for the heart attack and coronary bypass models….”

8. ”The cardiac bundles and the expanded CJR model qualify as Advanced Alternative Payment Models under the Medicare Access and CHIP Reauthorization Act and the Quality Payment Program.”

9. ”The American Hospital Association said it was pleased with some parts of the final rule, including the flexibility the rule provides regarding MACRA participation. However, the AHA expressed concern about the pace of change. ‘The bundled payment model for cardiac care is the second mandatory demonstration project the agency has finalized in just the past 15 months,’ said the AHA. ‘This is too much, too soon.”‘

10. The bundles will begin July 1, 2017.


Some hospitals send patients to nightmare nursing homes

 

nursinghome

By JORDAN RAU

For Kaiser Health News

At age 88, Elizabeth Fee looked pregnant, her belly swollen after days of intestinal ailments and nausea. A nurse heard a scream from Fee’s room in a nursing home, and found her retching “like a faucet” before she passed out.

The facility where she died in 2012 was affiliated with a respected San Francisco hospital, California Pacific Medical Center, and shared its name. Fee had just undergone hip surgery at the hospital, and her family, pleased with her care, said they chose the nursing home with the hospital’s encouragement.

Laura Rees, Fee’s elder daughter, said she was never told that the nursing home had received Medicare’s worst rating for quality — one star. Nor, she said, was she told that state inspectors had repeatedly cited the facility for substandard care, including delayed responses to calls for aid, disrespectful behavior toward patients and displaying insufficient interest in patients’ pain.

“They handed me a piece of paper with a list of the different facilities on it, and theirs were at top of the page,” Rees said in an interview. “They kept pointing to their facility, and I was relying on their expertise and, of course, the reputation of the hospital.”

Fee had an obstructed bowel, and state investigators faulted the home for several lapses in her care related to her death, including giving her inappropriate medications. In court papers defending a lawsuit by Fee’s family, the medical center said the nursing home’s care was diligent. The center declined to discuss the case for this story.

The selection of a nursing home can be critical: 39 percent of facilities have been cited by health inspectors over the past three years for harming a patient or operating in such a way that injuries are likely, government records show.

Yet many case managers at hospitals do not share objective information or their own knowledge about nursing home quality. Some even push their own facilities over comparable or better alternatives.

“Generally hospitals don’t tell patients or their families much about any kind of patterns of neglect or abuse,” said Michael Connors, who works at California Advocates for Nursing Home Reform, a nonprofit in San Francisco. “Even the worst nursing homes are nearly full because hospitals keep sending patients to them.”

Hospitals say their recalcitrance is due to fear about violating a government decree that hospitals may not “specify or otherwise limit” a patient’s choice of facilities. But that rule does not prohibit hospitals from sharing information about quality, and a handful of health systems, such as Partners HealthCare in Massachusetts, have created networks of preferred, higher-quality nursing homes while still giving patients all alternatives.

Such efforts to help patients are rare, said Vincent Mor, a professor of health services, policy and practice at the Brown University School of Public Health in Providence. He said that when his researchers visited 16 hospitals around the country last year, they found that only four gave any quality information to patients selecting a nursing home.

“They’re giving them a laminated piece of paper” with the names of nearby nursing facilities, Mor said. For quality information, he said, “they will say, ‘Well, maybe you can go to a website,’” such as Nursing Home Compare, where Medicare publishes its quality assessments.

The federal government may change this hands-off approach by requiring hospitals to provide guidance and quality data to patients while still respecting a patient’s preferences. The rule would apply to information not only about nursing homes but also about home health agencies, rehabilitation hospitals and other facilities and services that patients may need after a hospital stay.

“It has a substantial opportunity to make a difference for patients,” said Nancy Foster, a vice president at the American Hospital Association.

But the rule does not spell out what information the hospitals must share, and it has yet to be finalized — more than a year after Medicare proposed it. The rule faces resistance in Congress: The chairman of the House Freedom Caucus, Rep. Mark Meadows, R-N.C., has included it on a list of regulations Republicans should block early next year.

The government has created other incentives for hospitals to make sure their patient placements are good. For instance, Medicare cuts payments to hospitals when too many discharged patients return within a month.

“Hospitals didn’t use to care that much,” said David Grabowski, a professor of healthcare policy at Harvard Medical School. “They just wanted to get patients out. Now there’s a whole set of payment systems that reward hospitals for good discharges.”

But sometimes hospitals go too far in pushing patients toward their own nursing homes. In 2013, for instance, regulators faulted a Wisconsin hospital for not disclosing its ties when it referred patients to its own nursing home, which Medicare rated below average. In 2014, a family member told inspectors that a Massachusetts hospital had “steered and railroaded” her into sending a relative to a nursing home owned by the same health system.

Researchers have found that hospital-owned homes are often superior to independent ones. Still, a third of nursing homes owned by hospitals in cities with multiple facilities had lower federal quality ratings than at least one competitor, according to a Kaiser Health News analysis.

The Lowest Rating
But state inspectors found shortcomings in seven visits to the nursing home between August 2009 and October 2011, records show. Inspectors found expired medications during two visits and, at another, observed a nurse washing only her fingertips after putting an IV in a patient with a communicable infection. Medicare’s Nursing Home Compare gave the nursing home where Elizabeth Fee died one star out of five, meaning it was rated “much below average.” The hospital’s case managers told Fee’s family that the nursing home was merely an extension of the hospital and that “my mother would receive the same excellent quality of care and attention,” said Rees, her daughter.

Just four months before Fee arrived, inspectors cited the nursing home for not treating patients with dignity and respect and for failing to provide the best care. One patient told inspectors that her pain was so excruciating that she couldn’t sleep but that nurses and the doctor did not check to see whether her pain medications were working.

“Nobody listens to me,” the patient said. “I was born Catholic, and I know it’s not right to ask to die, but I want to die just to get rid of the pain.”

Fee ate little and had few bowel movements, according to the state health investigation. Fee’s family had hired a private nurse, Angela Cullen, to sit with her. Cullen became increasingly worried about Fee’s distended belly, according to Cullen’s affidavit taken as part of the lawsuit. She said her concerns were brushed off, with one nurse declining to check Fee’s abdomen by saying, “I do not have a stethoscope.”

On the morning of her death, an X-ray indicated Fee might have a bowel obstruction or other problem expelling stool, the inspectors’ report said. That evening, after throwing up a large quantity of matter that smelled of feces, she lost consciousness. She died of too much fluid and inhaled fecal matter in her lungs, the report said.

Bills Of More Than $150,000
Sutter Health, the nonprofit that owns the medical center and the nursing home, emphasized in court papers that Elizabeth Fee arrived at the facility with a low count of platelets that clot blood. Sutter’s expert witness argued that the near-daily visits from a physician that Fee received “far exceeds” what is expected in nursing home care.In a court ruling, Judge Ernest Goldsmith of the San Francisco Superior Court wrote that Nancy Fee’s younger daughter, Nancy, “observed her mother drown in what appeared to be her own excrement.” Kathryn Meadows, the family’s attorney, said in a court filing that the nursing home’s bills exceeded $150,000 for the three-week stay.

The physician and his medical group have settled their part of the case and declined to comment or discuss the terms; the case against Sutter is pending. California’s public health department fined Sutter $2,000 for the violations, including for delaying 16 hours in telling the physician about Fee’s nausea, vomiting and swollen abdomen. Last year, Sutter closed the nursing home.

A week or so after Fee died, a letter addressed to her from California Pacific Medical Center arrived at her house. It read: “We would appreciate hearing about your level of satisfaction with the care you received on our Skilled Nursing Rehabilitation Unit, the unit from which you were just discharged.”

 


AHA, AHIP chiefs press for wider insurance choices, lower drug prices

Rick Pollack,  president of the American Hospital Association, and Marilyn Tavenner, CEO of America’s Health Insurance Plans, in a joint essay in The Hill press for improving federal marketplace offerings and lowering the cost of life-saving drugs.

Among other things, they urge physicians, nurses, health plans and other in the healthcare sector to join to push cost controls.

But they also discussed  the successes  in cost control that have been achieved in such areas as Medicare Advantage, Medicare Part D, Medicare Shared Savings Program and Medicaid managed-care plans.

“A healthy private market – with real choice, informed consumers, and effective care and treatments – can deliver better quality and affordable coverage for everyone,” they wrote.

They added:  “Unjustified and unaccountable spikes in prescription drug prices are the engine of higher costs. Despite historic lows in overall cost growth for years, drug spending grew by more than 12 percent in 2014 – and is expected to outpace overall growth for the foreseeable future,” they wrote.

To read the piece from The Hill, please hit this link.

 


AHA again takes aim at CMS site-neutral rule

 

The AHA has again asked the Centers for Medicare & Medicaid Services to delay implementing  the site-neutral provisions of the Bipartisan Budget Act next Jan. 1, citing potential risk for hospitals to  violate the Stark law and Anti-Kickback statute.

Under the site-neutral rule, CMS would pay for services rendered in hospital outpatient departments at the same, lower rate it pays for  treatment in physicians’ offices. The proposal has engendered controversy since its announcement, with physicians and hospitals taking opposing views.

The AHA now has further ammunition in its push to delay the rule’s implementation. Parts of the rule would apparently make hospitals vulnerable to punishment  under laws restricting  hospitals’ provisions of free goods or services to referring physicians.

The AHA analysis concludes that hospitals could  unfairly suffer  by bearing the extra cost of operating their outpatient departments at ”no cost to physicians.”

To read a longer story on this, please hit this link.


Hospitals fighting revival of ‘the public option’

 

Hillary Clinton, under pressure from the left wing of the Democratic Party, is now pushing for “public option” coverage in the state and federal health insurance exchanges.

This would be a compromise between Sen. Bernie Sanders, who backs a “Medicare-for-all” approach, and the current  very complex system of private insurance partially paid for by employers, private insurance bought in insurance exchanges, and expanded Medicaid under the Affordable Care Act.

Polls have suggested that a majority of the public favors extending Medicare t0 all or at least a public option, in which people could chose government-financed insurance instead of coverage from a private insurer.

It appears that hospital executives oppose a public option because they fear that it would  cut the payments that hospitals receive to provide care. So the American Hospital Association and the Federation of American Hospitals  has sent this message  to the Democratic Platform Drafting Committee.

“Our members have serious concerns that creating a public option with Medicare-like payments would subvert those goals by depressing insurer payments to healthcare providers and disrupting the fragile finance system that sustains hospitals today.”

The letter asserted that two-thirds of the two groups’ member hospitals received Medicare reimbursements that are below cost of providing care, while the average operating margin on Medicare reimbursements for hospitals was negative 5.8 percent in 2014.

“Adding millions more enrollees whose healthcare would be reimbursed at Medicare rates would likely threaten access to needed healthcare services, particularly for those in vulnerable communities,” the letter said.

To read more, please hit this link.


AHA meeting denounces insurer-merger plans

 

It’s no surprise that hospitals don’t like health-insurer  mergers, as the American Hospital Association annual meeting on May 2 made clear.

They particularly don’t like  the two  biggest pending health insurer mergers — Aetna-Humana and Anthem-Cigna.

“The unprecedented level of consolidation that these deals threaten could make health insurance more expensive and less accessible to consumers,” moderator and AHA board member Thomas Miller said. “We are also very concerned that these deals could hinder the momentum that hospitals have established to move the nation’s healthcare system forward.”

The hospitals, of course, fear that the bargaining power of these behemoth insurers could slash their operating margins.

FierceHealthPayer reports that “Northwestern University Prof. Leemore Dafny has argued that, because while there is no definitive academic research proving that past insurer mergers have created cost efficiencies or improved quality and innovation, there is evidence that provider reimbursement decreases and that insurance premiums go up.”

“The data is also clear, she said, that the health-insurance sector is already composed of “highly concentrated markets that have grown more concentrated over time.”

At the same, federal and state  regulators have been eying skeptically various big hospital- system mergers as threatening higher prices in their markets.


Study questions value of some high-volume surgery

surgery

The general assumption for some years has been that higher-volume hospitals produce better outcomes in some surgical procedures and have lower patient-mortality rates. But a new study  in Applied Health Economics and Health Policy questions at least some of that conventional wisdom.

Rice University researchers said that the link between  a high volume of  procedures and good outcomes has been exaggerated. An analysis of data from the American Hospital Association Annual Survey of Hospitals from 2000 to 2011 found that high volume alone does not account for some hospitals’ surgery success, and that  many things can produce good  patient outcomes.

The team studied outcomes for six complex cancer operations that showed a link between high volume and positive outcomes. Previous studies relied on the simplest statistical models to determine the volume-outcome relationship. After using more sophisticated statistical models, they found that only four of the procedures benefited from higher-volume settings.

“If patients are in need of one of these operations, they most likely will rely on advice from their physician on which hospital to get treated at,” said Vivian Ho, study co-author and chairwoman of  health economics at Rice’s Baker Institute for Public Policy and director of the institute’s Center for Health and Biosciences.  “But physicians who consult the medical literature for guidance on where to send their patients may be getting incomplete information. The medical literature may be overemphasizing the role that hospital volume plays in patient outcomes.”

Last year, some  major providers limited procedures could be performed at low-volume hospitals and by low-volume “cowboy” surgeons who do  procedures that they don’t usually perform.


Free webinar: How to prosper in a bundled-payment world

Physician leaders,  hospital administrators and payers are among  those who will benefit from listening to the webinar “Physicians Design Success With Bundled Payments” on Tuesday, April 5, at 1-2 p.m.  EDT.  The program is hosted by the Society for Healthcare Strategy and Marketing Development, part of the American Hospital Association.

The session will explain how to make bundled-payment programs work to improve outcomes and  to address the intensifying demands of public- and private-sector payers for stronger cost controls. Much of healthcare is moving toward bundled payments. This webinar will help speed  you on your way in this new value- and evidence-based reimbursement world.

Speaking will be Dr. George Beauregard, chief physician executive at St.  Luke’s Health Partners, Boise, Idaho; Dr, Jack Frankeny, CEO of the Orthopedic Institute of Pennsylvania, in Harrisburg, Pa., and Bob Harrington, partner and senior adviser at Cambridge Management Group, Belmont, Mass.

Viewers may secure free access to this session by sending a request to rwhitcomb@cmg625.com.

 

 


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