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2019 outlook for not-for-profit hospitals not that grim

 

The financial outlook for not-for-profit hospitals has sounded  dismal for the past several years. As FierceHealthcare reports:

“They face ongoing pressures of soft revenue growth, weak inpatient volumes and single-digit reimbursement increases, pushing margins down as expenses outstrip revenue—a trend that Moody’s called an ‘unsustainable path,’ earlier this year.

New reports from the two top rating agencies—Moody’s Investors Services and Fitch Ratings—offer, for yet another year for not-for profit hospitals, a gloomy outlook for 2019. But, Fierce reports:

“[W]hile these hospitals face a tough road ahead, the news is not as bad as it might seem, said Kevin Holloran, senior director at Fitch who just gave the sector a ‘negative’ outlook.

“‘We’re putting warning flags up, but no ones calling for disaster,’ Holloran said. ”

”He acknowledged operating margins have been on the decline while hospitals deal with nontraditional competition, new technology changing the way medicine is practiced and the continued shift from inpatient to outpatient care. ‘But pretty much, however, you want to measure it, balance sheet strength is pretty much at an all-time high.”’

“He pointed specifically to hospitals’ days’ worth of cash on hand, as well as their cash-to-debt and debt-to-capitalization ratios as measures in particular that had been improving over time, leading to stable ratings for the sector.

“That’s because when times were good and the markets were rebounding several years ago, hospitals were building up their reserves and shrinking their capital expenditures.

“‘Until a significant market dislocation, we expect those balance sheets to remain kind of robust which is going to balance out the negatives from operations.”’

To read the whole article, please hit this link.


Healthcare price inflation speeding up

 

According to a report (PDF) from Altarum, healthcare prices grew 2.2  in April from a year earlier,  the highest rate since January 2012. Hospital price growth, the main culprit,  jumped 3.6 percent from a year earlier, mostly driven by a 4.6 percent price growth for Medicare patients and a 3.8 percent private-insurance price growth.

But Medicaid prices rose  only 1.6 percent.

More and more consumers are struggling to pay for the world’s most  expensive healthcare.

To read the Altarum report, please hit this link. To read FierceHealthcare’s take on the report, please hit this link.

 


Patients, families must speak up in hospitals

By EMILY BAZAR

For Kaiser Health News

My dad was in excruciating pain over Labor Day weekend, so my mom rushed him to the emergency room of a renowned university hospital.

Doctors determined that he needed surgery that night, and luckily I was able to fly in and see him before he was wheeled away. “Take care of your mom if anything happens to me,” he said as my mom and I wept.

Thankfully, my dad made it through. But he had to spend 11 days recovering in the hospital, a place he now equates with prison.

One night, he suffered for five hours, desperately calling for help after his pain meds had run out. A nurse’s aide stationed in his room had fallen asleep.

“I called on the intercom so many times, and nobody showed up,” he recounts.

That was just one of the many failures in care that we encountered during my dad’s stay. Others included inconsistent nursing quality, waiting all day for doctors to respond to pages, insensitive communication of bad news, trying in vain to reduce noise levels so my dad could sleep, and so much more.

My job is to give you advice on health care and insurance issues. My mom is a registered nurse. Yet we both felt frustrated that we couldn’t make things better for my dad.

Unfortunately, this happens to a lot of people. “Everything you hear these days is about patient-centered care, this and that,” says Terry Bay, who owns a Casper, Wyo.-based business that provides advocacy services to older patients. But “we don’t live in a patient-centered health care environment.”

Today I’m going to offer advice for you in case you or a loved one lands in a hospital.

There are state and federal laws that cover, among other things, your rights to privacy, nondiscrimination, language interpretation and visitation, says Lois Richardson, vice president and legal counsel of the California Hospital Association.

But beyond legal protections, there are people you can talk to and steps you can take to improve your situation if you feel you’re not getting the care you deserve. And patients’ opinions do count.

“All hospitals increasingly are being scored and paid based on patient and family satisfaction scores,” says Rebecca Kirch, an executive vice president with the National Patient Advocate Foundation. “There is power in the peopl

That power starts with a few simple things.

First, make sure a spouse, child, family member or friend — anyone concerned for your well-being — can spend time with you in the hospital and be your advocate. You cannot do it by yourself while you’re in pain, medicated and not thinking clearly.

“It’s having someone else in your court, someone who can check in and make sure your questions are being answered,” says Dr. Rebecca Sudore, a geriatrician and palliative care physician at the University of California-San Francisco.

Before you or your advocate speaks to your nurse or doctor, write down your questions. Keep track of your glasses, hearing aids and dentures — the personal belongings that most often go missing in hospitals, Sudore says.

“How can someone speak up for themselves if they can’t see someone? Or can’t hear?” she asks.

When the time comes to ask questions — or express frustration — don’t be afraid to speak up. You have every right, even though it can feel intimidating to question your doctors or complain about your nurses.

“You can say, ‘No, I don’t want to go for that test. I want to speak to my daughter first,’” Bay says.

If you’re getting jostled out of sleep for a blood draw or blood pressure check in the middle of the night, ask your doctor the next day if it’s really necessary. Often, it can wait till early morning, says Julianne Morath, president and CEO of the Hospital Quality Institute.

“It’s up to us to put our own humanity back into decisions,” Sudore says.

But here’s where speaking up can get thorny.

Let’s say you don’t feel you’re getting adequate care or you’re unhappy with how you’re being treated. You can start with your nurse, but if that’s uncomfortable — perhaps because that nurse is the source of the problem — approach the charge nurse, who manages the staff in your unit.

You can also ask to talk to a hospital-based social worker, who can intercede or help you figure out who to talk to, Kirch says.

If that doesn’t help, take your complaints to the next level.

Every hospital that participates in the Medicare program — which is most — must have an ombudsman or patient rights advocate, Richardson says. My mom and I eventually complained to the patient rights advocate. It helped, and we wish we had done it sooner.

If you can’t go to the patient rights advocate yourself, “you can call them or ask your nurse to call them and have them come up to your room,” Richardson says. Hospitals must acknowledge patient complaints immediately, she says, and must respond in writing once they are resolved.

As part of this process, no matter whom you talk to, there are some phrases that can spur quick action, Kirch explains. One is “This doesn’t feel like quality care to me.” Another is “I see my loved one suffering.”

If you have a serious illness and you’re suffering from symptoms that aren’t being managed correctly, you can also request a consultation with a palliative care team. Palliative care isn’t only about end-of-life issues, it’s about quality of life, Kirch says.

Most large hospitals have a multidisciplinary team of doctors, nurses, social workers, chaplains and others who can provide added support on top of the medical treatment you’re receiving, especially if you’re getting shuffled among medical specialties.

“They can help tremendously to fill in the blanks. … It can be pain management. It can be spiritual or psychological distress,” Kirch says. “The palliative care team treats the person beyond the disease.”

If you have done all that and still have concerns, Kirch’s organization has case managers who provide free, one-on-one support for patients. Call 800-532-5274 for more information or visit www.patientadvocate.org/help.php.

To be clear, I’m not suggesting you complain about every little thing. Be realistic. For instance, a hospital doctor may see up to 30 patients a day. So you might have to wait for your page to be answered unless you have a serious, potentially life-threatening problem, Sudore says.

“It may not be that you’re being ignored. It might be that someone has to figure out the competing priorities,” she says.

And don’t forget that your caregivers are human too, Morath advises. “They get tired, they get stressed,” she says. “Very often, just letting them know you’re not getting what you need and asking for their help … is a very powerful act.”


More states rescinding Medicaid ‘retroactive eligibility’

By MICHELLE ANDREWS

For Kaiser Health News

If you’re poor, uninsured and fall seriously ill, in most states if you qualify for Medicaid — but weren’t enrolled at the time — the program will pay your medical bills going back three months. It protects hospitals, too, from having to absorb the costs of caring for these patients.

But a growing number of states are rescinding this benefit known as “retroactive eligibility.” On Nov. 1, Iowa joined three states that have eliminated retroactive coverage for some groups of Medicaid patients since the Affordable Care Act passed. Each state had to secure approval by the federal government.

Retroactive eligibility has been a feature of Medicaid for decades, reflecting the program’s emphasis on providing a safety net for poor, disabled and other vulnerable people. In contrast to private insurance, determining Medicaid eligibility can be complex and the application process daunting, advocates say. A patient’s medical condition also may keep families from applying promptly for coverage.

All four states — Arkansas, Indiana and New Hampshire, in addition to Iowa — have expanded Medicaid under the health law, which allowed states to include adults with incomes up to 138 percent of the federal poverty level, or about $16,000 for one person. So, in theory, most adults are required to have insurance under the ACA. In practice, each state still has a significant number of uninsured, ranging from 5 to 8 percent of the population.

The retroactive coverage “can compensate for the sorts of errors and lapses that can so easily occur on the part of both the applicant and the government bureaucracy” that delay applications, said Gordon Bonnyman, staff attorney at the Tennessee Justice Center, a public interest law firm that represents low-income and uninsured residents.

State and federal officials say eliminating the retroactive coverage helps encourage people to sign up for and maintain coverage when they’re healthy rather than waiting until they’re sick to enroll. It also fits into federal officials’ efforts to make Medicaid, the federal-state program that provides health care for low-income adults and children, more like private insurance.

But consumer advocates and health care providers say the shift will saddle patients with hefty medical bills and leave hospitals to absorb more uncompensated care when patients can’t pay. Some worry this could be the start of a trend.

In Iowa, the change applies to just about anyone coming into Medicaid — except for pregnant women and children under age 1. The change will affect up to 40,000 residents annually and save the program more than $36 million a year.

“We’re making it a lot more likely that Medicaid-eligible members are going to incur significant medical debt,” said Mary Nelle Trefz, health policy associate at the Child & Family Policy Center, in Des Moines, whose organization opposed the change.

When someone has a traumatic health event, the initial focus is to get them stabilized, not figure out how to pay for it, said MaryBeth Musumeci, associate director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Patients may neglect to apply immediately for Medicaid, leaving them financially responsible for days or months of care they received before they got in their application, even though they may have been eligible for Medicaid all along.

That’s not the only issue, advocates say. Unlike the commercial insurance market where re-enrollment through someone’s employer is routine, Medicaid requires that beneficiaries’ eligibility be reassesed every year.

“People fall through the cracks,” said Andrea Callow, associate director of Medicaid initiatives at Families USA, a consumer advocacy group.

In addition, complications can arise for people who might need Medicaid coverage for long-term care services. “The criteria are complicated. For a layperson to find those criteria and figure out if they’re eligible” is challenging and they may need extra time, said Musumeci. Once patients have secured coverage, they may already have accrued hefty expenses.

Maybe so, but some people argue that a 90-day retroactive eligibility guarantee is counterproductive.

“We’re trying to get people to behave more responsibly, not less responsibly,” said Gail Wilensky, an economist who oversaw the Medicaid and Medicare programs in the early 1990s under President George H.W. Bush. “That is not the signal you’re sending” with three months of retroactive eligibility. A 30-day time frame is more reasonable, Wilensky said.

In contrast to Iowa, the waivers in Arkansas, Indiana and New Hamsphire generally apply only to adults who gained coverage under the law’s Medicaid expansion. (Indiana’s waiver also applies to other groups.)

Kentucky has a request pending that, like Iowa, would eliminate retroactive Medicaid eligibility except for pregnant women and children under 1, according to KFF.

Under federal law, officials can waive some Medicaid coverage rules to give states flexibility to experiment with different approaches to providing services. And retroactive eligibility waivers in Medicaid are hardly new. A few states like Tennessee have had them in place for years. Tennessee officials eliminated retroactive eligibility for all Medicaid beneficiaries in 1994 when the state significantly expanded coverage under TennCare, as Medicaid is known there. At the time, the state even allowed uninsured people to buy into the program who wouldn’t otherwise qualify based on income, said Bonnyman.

“There was no reason for anybody to be uninsured except undocumented immigrants,” said Bonnyman. “It didn’t seem to have the potential for harm.”

But state officials revamped that program after serious financial problems. Eligibility for TennCare has become more restrictive again.

Other states that waived retroactive coverage for at least some Medicaid groups include Delaware, Maryland, Massachusetts and Utah, according to the Kaiser Family Foundation.

Bonnyman said his group frequently works with Medicaid beneficiaries who have medical bills they can’t afford that accumulated during the months before they applied for Medicaid.

“If you’re a moderate- to low-income working family, one or two days in the hospital is enough to ruin you financially,” he said.

 


Holding hospital boards accountable for institutional culture

 

Healthcare analyst and consultant Paul Keckley, Ph.D. has looked at how hospital boards  should be held accountable for their institutions’ culture.

He noted:

“On Wednesday, Oct. 4, the National Association of Corporate Directors released a report from its 34-member commission outlining 10 recommendations that would encourage boards to be more proactive in attending to corporate culture. They include the formal measurement of culture, the inclusion of culture considerations in performance reviews of top managers, changes to incentives in short- and long-term compensation and others. Their bottom line is this: Boards must understand how an organization achieves results, not just the results themselves. ”

He writes about:

“Board education: …. Nonprofit boards underinvest in board education and many are lax in evaluating their boards. Complex issues like private inurement, the False Claims Act, HIPAA and many more require more than casual understanding by trustees.”

“Culture monitoring processes: Hospital boards must create a formal process for monitoring the culture in their hospitals. Most hospitals conduct employee surveys and share the results with the board. Many of these include comparisons to other organizations and best practice recommendations. But in the future, boards must go deeper. The work climate in most hospitals is stressful. The workforce is expected to do more with less and alter work habits as clinical innovations and payment schemes force change. Boards must examine the mechanisms whereby the workforce is managed, promotions awarded, recognition and compensation given.”

To read his whole commentary, please hit this link.

 

 


Fee-for-service system extends patients’ wait times as providers seek to maximize profits

 

Many patients are becoming increasingly frustrated and angry because of the very long waiting times  in many hospitals and physicians’ offices, in part caused by overbooking.

Providers say they recognize the problem but don’t see it as a priority. That’s because their revenue and profit depends on keeping a steady flow of customers to ensure that  examining rooms (and waiting rooms!) are kept as full  as possible.

As an article in The New England Journal of Medicine noted:

“Physicians and practices might think they minimize the clinical consequences of long waits by prioritizing the patients they squeeze in by double-booking. For example, all else being equal, a hematology–oncology practice might schedule the patient with a known cancer faster than the one with a benign hematologic issue, or a cardiology practice might accommodate a patient with complex arrhythmia sooner than one with stable angina. This approach not only makes sense clinically; it’s also good business. Higher-acuity conditions tend to drive more tests and procedures, which translates to more services billed and more dollars collected. In fact, in busy practices that maintain a patient mix heavily weighted toward sicker patients, improving access for patients across the board could bring down the average weighted productivity and profitability.

“The painful reality is that the fee-for-service system rewards long waits and overbooking to squeeze in sicker patients. Practices maintain a higher-acuity mix, while health systems benefit from care spilling over into more costly settings. The system does not reward providers who organize care to reduce waits for all patients, even though that might keep some patients from becoming sicker. And that may be why most providers have been slow to invest in systems that might reduce waiting time.”

To read the NEJM article, please hit this link.

To read a Boston Globe article on this issue, please hit this link.


How much do Yelp reviews improve healthcare?

An article in Health Affairs looks at the growing “Yelpification” of U.S. healthcare, citing an April 2017 New York State Health Foundation (NYSHealth)-funded study,  in which the conservative Manhattan Institute explored how much Yelp ratings of hospitals in New York State correspond to objective outcomes measures across all of a hospital’s patients.

The Health Affairs piece reported: “The study found that higher Yelp ratings are correlated with better-quality hospitals and can offer consumers a useful, clear, and reliable tool that can be easily accessed. In short, for one very important measure—potentially preventable readmissions—Yelp ratings appear to have a moderately strong correlation with that measure. That is, higher Yelp scores for hospitals are associated with lower readmission rates.”

“But while this research has helped to move the needle on validating Yelp as an important asset in the tool chest of health care quality tools, there are still important questions left unanswered.

“For starters, do the disparate (and often contradictory) messages from existing rating systems have the potential to help non-savvy patients identify higher quality providers? Or do those messages just lead such patients to throw up their hands in frustration?

“Whether Yelp ratings contribute to this potential confusion or help generate greater understanding isn’t clear yet. Indeed, Yelp ratings of hospitals are in their infancy—relatively low sample size over the years and concentration in more urban areas mean that a wait-and-see approach might be best. However, the hope is that consumers’ trust of Yelp as a platform, and the open-ended, more personal nature of reviews, will over time build up into a useful metric of hospital quality.

“Both insurers and providers should also explore how user-generated reviews can help them to obtain information about patients with different needs—here, the free-form style of Yelp text reviews can be an advantage, in both understanding what patients value most and what they are most concerned about.”

To read more, please hit this link.


Using hospital-satellite emergency departments to reduce strain on hospitals

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Most hospital emergency departments seem to get busier and more crowded each year, placing ever-greater strains on patients and clinicians. Ricardo Martinez, M.D., suggests that hospital-satellite emergency departments (HSEDs) can offer considerable relief.

He writes in Hospital Impact that they “provide a more distributed access model of emergency care that can be integrated into the healthcare system to relieve the strain on existing EDs and bring emergency care closer to patients.

“HSEDs are structurally separate from a hospital, but offer patients emergency services that are equal to or surpass those at hospital-based facilities. The acuity levels for patients seen in HSEDs are similar to those seen at hospital-based EDs as well (broken bones, burns, chest pain, abdominal pain, pulmonary symptoms, head traumas and concussions). In short, when it comes to treatment, there is little to no difference between the two types, but HSEDs have the ability to provide more accessible and a greater value of care.

“Having multiple HSEDs throughout local communities expands access to emergency medical care for more patients, including those who live far from a centralized hospital system. This type of medical delivery system is already implemented with decentralized imaging centers, laboratories and urgent care centers.”

To read more, please hit this link.


Higher physician spending doesn’t help hospital patients’ outcomes

 

A study published in JAMA Internal Medicine found that higher spending on physicians doesn’t lead to better  outcomes for patients who have been hospitalized.

The study included data from a little more than 72,000 physicians over 1,324,000 hospitalizations of Medicare beneficiaries.

The authors found that, perhaps unsurprisingly, spending variation is greater among than physicians than among hospitals.

They said the data “suggest that not only does physician spending vary substantially even within the same hospital, but also that higher-spending physicians do not reliably achieve better patient outcomes.”

The authors point out that many payment-reform and value-based care efforts are targeted to hospitals that, it is assumed, can help influence physician behavior.  They  suggest that this targeting should also directly include physicians,  to help cut  costs.

“Our findings suggest that higher-spending physicians may be able to reduce resource use without compromising patient outcomes. Policy interventions that target physicians within hospitals (e.g., physician-level pay-for-performance programs and reporting of how resource use of each physician compares with other physicians within the same hospital) should be developed and evaluated.”

“Among both hospitalists and general internists, physicians with higher spending per hospitalization had no detectable differences in 30-day mortality or readmissions compared with lower-spending physicians within the same hospital. Given larger variation in spending across physicians than across hospitals, policies that target physicians within hospitals may be more effective in reducing wasteful spending than policies focusing solely on hospitals.”

To read the JAMA piece, please hit this link.


Timothy J. Babineau, M.D.: Look at what works well in U.S. healthcare and build on that

 

American healthcare is expensive. Too expensive. On this, there is little debate. In 2001 the median U.S. household spent 6.4 percent of its income on healthcare; by 2016, the same household spent 15.6 percent of its income on healthcare. That bigger share of the pie leaves less for other essential purchases such as food, education and housing.

The same phenomenon exists at the national level, with spending on education, the environment and social programs getting squeezed. Recent estimates from the Centers for Medicare and Medicaid Services (CMS) have the American healthcare tab coming in at $3.6 trillion for 2016 and projected to continue to soar through 2025. Despite broad agreement that rising healthcare costs are unsustainable, the root causes of the rates of increase and the best ways to combat them remain the subject of some debate and confusion.

Numbers matter. The 80/20 rule—known to healthcare actuaries as the Pareto principle, posits that 80 percent of all medical spending is incurred by only 20 percent of the population. Whether a population is defined as a company, a county, or a country, most healthcare spending is for care of a small minority of individuals. Moreover, the bulk of that spending arises from either largely unavoidable or unpredictable single events (such as trauma or sudden-onset acute illnesses); such chronic conditions such as diabetes; complex episodes of care for such illnesss as cancer, and care delivered at the end of life.

A critical (but often overlooked) point is the fact that as much as 40 percent of spending during chronic and complex episodes is avoidable if providers and systems adhere to established standards of care. Reining in runaway healthcare spending must involve better management of high-cost episodes of chronic and complex care.

A key buzzword in today’s debate is “population health”. Confusion occurs when the term is interpreted as a strategy for controlling healthcare costs when it is applied across our entire population as opposed to the sickest 10 percent or 20 Percent. Wellness initiatives, early detection, the avoidance of emergency room visits, and disease prevention have undeniable value, and should all be pursued, but they will not (by themselves) sufficiently reduce healthcare spending by enough to make the system “affordable”.

As the Baby Boomers swell the ranks of Medicare beneficiaries, the inevitability of illness is the only certainty in an otherwise uncertain world. To be successful, programs, payment systemsand policies to curb healthcare spending must focus on improving the efficiency and effectiveness of care delivered to the sickest subset of the population. This is best accomplished within a completely integrated healthcare-delivery system.

American hospitals and healthcare systems are among the best in the world. Rather than asserting that “American healthcare is broken” and in need of rebuilding from scratch, a better strategy may be to look at what works well within our system and ask how we can build on those strengths while facing the escalating costs head on. Hospital systems are in the health care business, and we should not be reluctant to say so. No matter what wellness and prevention programs we collectively offer, inevitably a small subset of the population will still get very sick, and it is a core mission of health systems—working in close partnership with our primary and specialty providers—to take the very best and most efficient care of them when that happens.

Irrespective of what happens with the Affordable Care Act (ACA), as leaders in health care, we must redouble our efforts to eliminate unnecessary variations and wasteful spending in the clinical care we deliver to patients.

Rather than debate the actual percentage that is “wasteful spending” (now commonly referenced at around 30 percent) we would be better served by continuing the hard work of identifying and eliminating areas within our own systems where needless variations in care add cost without improving outcomes. As Lifespan, the system I lead, continues to evolve into a comprehensive, high-value, integrated healthcare system, we are doing just that.

Timothy J. Babineau, M.D., is president and chief executive of Providence-based Lifespan, a large hospital system, and a professor of surgery at the Warren Alpert Medical School of Brown University.

 


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