Hospitals

QUALITY: It's About BETTER Health Care, Granny

Tom Emswiler — Fri, 21 Aug 2009 12:32:00 -0400

When you have a chance, get the grandparents away from watching those blood-pressure raising town halls on their televisions, and tell them this. Health reform is not about chopping Medicare. It's about making it better. And saving lives.

A test program now in its fourth year has shown how it can work. Hospitals that do a great job get rewarded. Those with a poor performance, get penalized.

Premier, Inc., a health care alliance based in North Carolina, released the results of year four of their landmark Medicare demonstration project this week. You might remember last year I blogged about year three, one of the first instances of a pay-for-performance initiative enforcing financial penalties on low-performing providers. I even got a tiny mention on Modern Healthcare (free registration required).

Year four again brought good news about higher quality. BNA says:

According to Premier, the quality improvements saved the lives of an estimated 4,700 heart attack patients in four years. The more than 1.5 million patients treated in five clinical areas at the 230 participating hospitals also received approximately 500,000 additional recommended evidence-based clinical quality measures, such as smoking cessation, discharge instructions, and pneumococcal vaccination.

This is great news -- 225 hospitals will receive payments totaling $12 million this year. It's a drop in the bucket for such a large number of hospitals, and a drop in the ocean compared to our $2.2 trillion health system. But by definition this is a smaller scale project that we can learn from (involving about 4 percent of U.S. hospitals), and the principle is right on target. Value-based purchasing results in better patient care.

Can this go nationwide? Not yet. CMS (the agency that runs Medicare) cannot make a program like this mandatory without an act of Congress. Additionally, CMS told us it would be hard at this point to expand outside of Premier, since they collect the data for CMS. But Premier informed us that they'd be willing to do that for non-Premier hospitals. Plus, only about ten percent of their members are participating - so there's room to grow there, too.

What's more, the principles and practices can be applied in different ways (keep reading!)

Last year, the real story was that Premier assessed penalties on nine hospitals that failed to improve against benchmarks. We have learned that three paid the penalty for year four, a total of $42,000. This is an extremely minor amount of money in terms of a hospital's total revenue, but it makes it a true value-based purchasing program. Penalties are an important part of value-based purchasing -- otherwise this is just another opportunity to pump more money into the health care system

It's the Physician Group Practice demonstration, though, with the real money. This demo encourages physician practices to coordinate care for the chronically ill. If costs rise slower than expected, the practice gets to keep 80 percent, and CMS gets 20 percent. BNA reports that the Marshfield Clinic in Wisconsin will alone receive nearly $14 million for year three of this demonstration. Dartmouth-Hitchcock, Geisinger, and two other practices will receive seven-figure payouts as well.

What can we learn from all this? Premier released a great document recently that discusses how providers of all shapes and sizes can improve quality. And as I learned at a briefing at Premier's DC offices a couple years ago, hospitals where the board and the physicians were highly engaged were much more successful than those hospitals that did not have those two commitments.

Certainly on this blog, we are building the case that there are a number of resources to help physicians and hospitals provide quality care. The key is getting them to work together so that patients receive care that is safe, timely, effective, efficient, equitable, and patient-centered every time.

HC4HCR: Checking In With Ascension, Denver Health

Meredith Hughes — Tue, 18 Aug 2009 19:40:00 -0400

This week, Kaiser Health News shined the spotlight on two high-performing health systems. KHN talked to Ascension Health President and CEO Anthony R. Tersigni, EdD, FACHE, and Denver Health CEO Patricia A. Gabow, MD, about the current health care reform debate, and what reform will mean for their health systems.We've highlighted both these health systems on this blog (here, here, here). Read more about them on the Health CEOs for Health Reform site.

Ascension Health is the nation's largest Catholic and largest nonprofit health care system, with over 60 hospitals in 20 states and the District of Columbia. Ascension Health serves patients through a network of services, including acute care services, long-term care, community health services, psychiatric, rehabilitation and residential care.

Dr. Tersigni told KHN that health care reform should feature a strong focus on covering the uninsured, then work on the other important issues facing U.S. health care, improving quality and controlling cost. For many hospitals, the cost of treating the uninsured is a huge strain. Uninsured patients tend to utilize costly emergency room treatment when serious health problems arise, as they lack access to the regular primary care visits that might have prevented the emergency in the first place. KHN reports that Ascension Health's bad debt from treating uninsured and underinsured patients grew by $167 million, or 23 percent over the past year as the economy worsened. He said,

We're concerned with making sure people have insurance rather than the dollar amount. We're taking care of these people anyway. We feel focused on let's get everyone 100% access, 100% covered. Then worry about how to make that work.

Dr. Tersigni is optimistic about reform. He believes we're closer to reform than we've been in over 60 years, and to miss this opportunity would be a tremendous waste.

Denver Health (which KHN points out is just a few hundred miles from the high-performing health community in Grand Junction) is an "integrated" health care network consisting of hospitals, clinics, and other community-based health services, such as correctional care and a 24-hour medical call center. To promote quality and lower cost, Denver Health utilizes health information technology and has followed the "LEAN" model to create a high-value efficient system which, according to Dr. Gabow, emphasizes getting five things right.

...Five rights -- the right physical environment, built for quality and safety and to support employees, patients and families; the right person in the right job; the right communication and culture; the right processes; and the right rewards.

Dr. Gabow believes national health reformers could learn from Denver Health's system's accomplishments. She told KHN,

To date, since 2006, we have saved $27 million by eliminating waste and making all the processes better. We did that without laying off anyone or cutting any care to the uninsured.

Health CEOs for Health Reform is a New America coalition of health industry leaders who believe that health reform is an urgent priority. Their leadership provides positive examples and shows that high quality, sustainable health reform is possible.

HC4HR: A New Model for Accountable Care

Paul Testa — Mon, 10 Aug 2009 21:37:00 -0400

Recently we had the chance to sit down and talk with Donna Katen-Bahensky, the president and CEO of University of Wisconsin Hospital and Clinics and a member of Health CEOs for Health Reform.

In the video below, Katen-Bahensky describes her organization's efforts to change the dynamics of modern medicine through the principles of accountable care organizations (ACO).

The academic medical center operates as part of UW Health -- a consortium of health care related entities that includes the UW School of Medicine and Public Health as well as a commercial health insurance plan and the largest academic, multispecialty physician group in Wisconsin. As such the organization's ACO has had particular success breaking down the silos of care that exist today and encouraging doctors, nurses, pharmacists, and all of the members of the health care continuum to work together as a team as the care for patients.

As Katen-Bahensky notes, this collaborative model has been especially important for primary care -- realigning the incentives to make field more attractive and viable to new doctors. Furthermore the consortium's commitment to the community through programs like the rural residency program, has helped create an environment where nearly two-thirds of the doctors it trains continue to practice in Wisconsin after graduation.

UW Hospital and Clinic's integrated approach has produced significant clinical and quality achievements as well. Like Denver Health, it has used health IT to improve the quality of care for patients -- particularly in the ICU. Like Ascension Health, UW Hospital and Clinics has focused on measuring and improving clinical outcomes. The health system consistently performs above national benchmarks for patient satisfaction and its post surgical mortality rates are especially impressive.

In part because of the way we finance graduate medical education, academic medical centers like UW Hospital and Clinics face an incentive structure that is like fee for service on steroids. Thus, like all of the members of Health CEOs for Health Reform, UW Hospital and Clinic's willingness to change its business model is courageous. Furthermore, its ability to do so while improving the quality of care it delivers and creating a system that values primary care is actually attractive to doctors, is proof that changes we need as a nation are not just possible but already in practice.

QUALITY: More Quality Improvements at Providence Medical Center

Meredith Hughes — Mon, 03 Aug 2009 21:22:00 -0400

We wrote recently about Providence Medical Center in Everett, Washington, and itsr innovations in health care quality. Everett now gets a look as one of "10 model communities throughout the USA able to provide top-notch care at relatively low prices" writes USA Today.

Over the past five years or so, the hospital expanded the leadership role of physicians to promote consistency and quality in care delivery, and in trying to address all the things that can go wrong when a patient transitions from one care setting, or care provider, to the next. . USA Today highlighted another one of Providence's quality innovations, shortening length of hospital stay and improving patient satisfaction during and after heart surgery. That involved re-examining care transitions too.

Providence is one of the few U.S. hospitals to create a "single-stay" heart surgery unit so patients remain in one place from the moment they leave the operating room until they're discharged. As patients need less life-support technology, it's simply removed from the room.

"We've had a dramatic increase in patient satisfaction, staff satisfaction and cut the length of a heart surgery stay by 10% to 15%," Providence Medical Center CEO Dave Brooks told USA Today, adding that patients suffer fewer complications and are less likely to need readmission to the hospital.The patient stayed put -- the machinery transitioned.

Disparities in health care costs and outcomes in hospitals across the U.S. provide yet more evidence that our health system is broken and needs to be fixed. Success stories in places like Everett show us that a solution is possible -- we can have high quality, affordable care for everyone.

QUALITY: Revisiting Readmissions

Joanne Kenen — Tue, 28 Jul 2009 17:49:00 -0400

We wrote about the high rate of hospital readmissions recently on the blog and for The Washington Post/Kaiser Health News. Today, both the Wall Street Journal and NPR examine the problem, both focusing (as we did) largely on older people with heart disease.

NPR's Joseph Shapiro told the story of Jessica MacLeod, a nurse with advanced training at the University of Pennsylvania Health System in Philadelphia. (We've written about Penn's Mary Naylor and their Transitional Care Model, too, here and here). MacLeod gets to know her patients in the hospital, and then follows them at home for two or three months, with particular attention to those first 48 hours when lots of things can go wrong.

One of her patients is Ken Rogers, 80, a retired superviser at a printing company. He recently spent a week in the hospital after experiencing chest pains.When he was hospitalized in the past, he recalled, "when I came out of the hospital, you go, 'Yeah? What do I do now?' It was, 'See ya,' " This time MacLeod was at his home within a day, and she returned often.

She reviews the instructions Rogers got from his cardiologist and takes the couple's questions about the medication he has just started to treat his atrial fibrillation and what foods he needs to avoid as a result.

"Mr. and Mrs. Rogers, I would consider very smart and savvy people -- and assertive," MacLeod says. "And even having those skills, health care is complex, and we have a health care system that is increasingly complicated. And, you know, if you've ever been to the doctor's office yourself, you are hearing words for the first time and they're maybe said once and it's hard to get a word in edgewise sometimes and say, 'Wait, what is atrial fibrillation, Doc?' You know, what does that mean? So part of my job is a translator, really, and I translate the language of health care to a layperson's language."

The care is expensive, although Naylor cites research showing it saves about $5,000 per Medicare patient each year.

The Wall Street Journal looked at the efforts to keep congestive heart failure patients out of the hospital -- and away from hot dog stands. Even on the Fourth of July, CHF patients can't afford all that salt, particularly if they already have a plate full of sodium-rich foods. The article focused on a program at Berkshire Medical Center in Pittsfield, Mass. They are using a combination of techniques -- telephone monitoring, clinics, medication counseling -- to keep people stable and out of the hospital. But the hospital makes money when people are admitted. Keeping them out of the hospital is not good for Berkshire's bottom line (although experts and hospital executives I interviewed when working on my story said that's true at some hospitals but not at all.)

Hospitals naturally worry about being punished for doing the right thing. And in the current system, some have reason to worry. But a goal of health reform -- at least the "cost-bending" and quality improving part of health reform -- is to change the incentives and get them right. That means turning our system from one that rewards quantity of care and crisis care to one that rewards quality of care and managing diseases before they turn into crises. There are a lot of approaches to try -- medical homes, accountable care organizations, bundled payments, transition benefits. Some of the hospitals and health care systems that are bringing down readmission are thriving. Now we have to help the rest of them find a way of improving care, in a reshaped system where the incentives help them do the right thing.

QUALITY: Stopping the Mistakes

Meredith Hughes — Tue, 21 Jul 2009 16:58:00 -0400

All health systems, even good ones, make mistakes. Some have horror stories. Surgical sponges left inside of patients, deadly infections that come from within the hospital rather than the outside world, operations on the wrong body part. Within the past few years, Virginia, Maryland, and DC have enacted laws requiring hospitals to disclose such patient injuries to regulators, The Washington Post reports. The goal is to make the system safer.

Regulators are hoping to reduce preventable deaths and injuries, sometimes called "never events" because they should "never" happen. According to the Post, one hospital in Northern Virginia reported about two dangerous blood infections for every 1,000 IVs inserted in patients. Currently, insurance companies generally reimburse hospitals for medical errors. If, for example, a patient were to come into the hospital for a low cost procedure, and get an infection from an IV because their doctor did not wash his hands, the hospital would bill the insurance company for the much higher cost of treating the hospital acquired infection. As the Post puts it, "if a lawn service mowed down your rosebush while cutting the grass, you wouldn't pay the company to replace it."

Some regulators and insurance providers are starting to come up with strategies to fight against these "never events" by realigning payment incentives. Medicare already implemented this system -- there are specific "never events" that Medicare won't pay hospitals for, including ventilator-associated pneumonia and hospital acquired staph infections. Some hospitals in Maryland are voluntarily cooperating with insurers who want to follow Medicare's example; agreeing to forgo reimbursement for mistakes such as transfusing people with the wrong blood type, or performing surgery on the wrong side of the body, reports the Post. Anthem Blue Cross and Blue Shield of Virginia also stopped paying for a small number of serious, preventable mistakes, such as operating on the wrong patient, or leaving foreign objects inside the patient after surgery.

Clinicians and hospital workers are only human, and people do make mistakes. But the potentially cataclysmic consequences of mistakes in patient care mean that hospitals and clinicians -- and the systems they work in -- need to strive toward perfection in care delivery. Doctors don't intend to make mistakes, and patients and their families don't like feeling victimized. (In fact, many have found that a sincere "I'm sorry" from doctors does a lot to alleviate the burden of medical malpractice lawsuits, reports the Associated Press.) Other simple strategies, such as Dr. Peter Pronovost's hygiene checklist, have helped hospitals lower rates of hospital acquired infections when implemented, but no method is foolproof. Health care providers are also worried about understaffing -- how strict is too strict for nursing staffs that are already chronically understaffed? Ultimately, the goal of changing payment incentives is to improve the health care system, to reduce medical errors, increase quality, lower cost, and improve patient safety.

COST: Emergency Room Utilization on the Rise

Meredith Hughes — Mon, 13 Jul 2009 22:02:00 -0400

Americans are still feeling the effects of the recent economic recession. Many who have lost their jobs have also lost their health care coverage, leaving hospital emergency rooms inundated with people seeking care, according to the Washington Post.

This year, DC's Providence Hospital reported emergency room visits increased by 13 percent. Larry Gage, president of the National Association of Public Hospitals and Health Systems, told the Post, "The absolute number of people using emergency rooms has gone up as much as 20 to 30 percent in the last six to eight months due to the recession and people losing their jobs. The only option in their minds is going to the hospital."

This trend is visible not just in DC and the surrounding area, as the Post reports, but across the nation. Back in April, the American Hospital Association reported that approximately 60 percent of hospitals were seeing more uninsured patients in their ERs, and 70 percent of hospitals were seeing higher rates of uncompensated care.

The problem with emergency room care, as we've discussed before, is that an ER is not a good substitute for primary care. The ER is just that -- a place for emergencies. And emergency treatment is far more costly than simple preventative measures. Additionally, hospitals have no way to provide emergency care for free -- it, like all other care, costs money. The cost of ER care for uninsured patients doesn't disappear. Uninsured patients often are billed directly for treatment but are unlikely to have the ability to pay. This cost strains hospital budgets and can be indirectly shifted onto families and individuals that do have insurance coverage in a "hidden tax" of higher premiums (Most estimates put the hidden tax somewhere between $1,000 and $1,300)

"I'm hearing a lot of people say: ‘Please help me. I lost my job,'" Raolat Abdulai, director of Howard's free clinic, told the Post. "It just shows how desperate things are right now. People really need health care."

An alternative to emergency room care, regardless of insurance status, is a community health clinic. The Post reports that community clinic utilization in Montgomery County has also increased recently, up by 43 percent in the past year. We've argued many times that wellness and preventive care saves money and improves patient health, something which is especially true for the uninsured who seek care in emergency rooms. Many community health centers have received federal stimulus funds, in hopes of expanding their outreach to more patients.

Albertha Boone, a DC resident, suffers from asthma, high blood pressure, and needs knee surgery, but she is unable to afford health insurance and relies on ER visits and over the counter medication to manage her conditions. Rather than seek emergency room care, Boone would probably benefit greatly from visits to a community health clinic. Instead of waiting for her hypertension to grow into something more serious (such as a stroke), she could receive check-ups from a primary care doctor and prescription medications that would allow her to manage her condition.

As we follow the health care debate, (and we know it's easy to get caught up in the drama of DC) it's important to remember why we're having this debate in the first place. Most Americans are not getting the care they need and deserve from our health care system. When we talk about fixing the health care system, we're talking about everything that goes into that conversation -- bringing down costs, improving quality, and making sure that everyone has sustainable, affordable coverage. It won't be easy, but it is necessary.

COST: White House Announces Deal With Hospitals to Save $155 Billion

Meredith Hughes — Wed, 08 Jul 2009 18:07:00 -0400

At a press conference this morning, Vice President Joe Biden formally announced that deal you've been hearing about with the hospitals, who have agreed to forego about $155 billion in government payments over the next 10 years. That only happens if health reform happens -- but the deal itself will help health reform happen.

Biden and HHS Secretary Kathleen Sebelius were joined by representatives from the American Hospital Association, the Hospital Corporation of America, Community Health Systems, and the Catholic Health Association of the United States.

"The very groups we have been talking to have been the most vocal opponents of health care reform; they are now becoming the vocal proponents for health care reform," White House chief of staff Rahm Emanuel told the New York Times.

The Times reports that Senators Chris Dodd (D-CT) and Olympia Snowe (R-ME) are cautiously optimistic about the deal. "I'm delighted to hear that people are stepping up to help reduce costs," Dodd, who has been leading the HELP committee health legislation markup in Sen. Kennedy's absence, told the Times, "but I want to know what the ask is, and the ask sometimes can exceed the value of your cost savings." (Eric Pianin and Phil Galewitz at Kaiser Health News have some more on what the hospitals may be concerned about, including federal financing of medical residency programs, charity care rules, and of course the fate of the public health insurance option.)

Tom Daschle suggests that health stakeholders realize what they stand to gain from health reform. "It's kind of a give-and-take, quid pro quo kind of environment," he told the Times. Taking an early seat at the table means "groups like the drug makers and hospitals will be owners of this process, and as owners they have to continue to defend it and support it."

With all the unoptimistic talk of bumpy roads, roadblocks, and the race against the clock, it's good to know that health care reform actually is moving ahead. No one said this was going to be easy! Remember -- we're talking about big and complicated but necessary changes to a large part of our economy. What is important about this deal? Everyone's invested in fixing the broken system, both the White House and the health industry are staying at the table, and the savings promised by this deal shows that it is possible to bend the cost curve. And in our book, that's good news.

HEALTH REFORM: Hospitals To Provide $155 Billion In Savings

Alex Mazerov — Tue, 07 Jul 2009 15:30:00 -0400

In a deal expected to be officially announced on Wednesday, July 8, the U.S. hospital industry has agreed to provide $155 billion in savings to help pay for health care reform, Ceci Connolly and Michael Shear write in today’s Washington Post.

The agreement, reached between the White House, the Senate Finance Committee, and three major hospital groups, calls for the savings to be phased in over a ten-year period. From The Post:

Most of the savings—about $100 billion—would come through lower-than-expected Medicare and Medicaid payments to hospitals, said the two industry sources. About $40 billion would be saved by slowly reducing what hospitals get to care for the uninsured, they added. The reductions would probably not begin for several years after a significant number of people have enrolled in the new insurance programs.

In addition, the three hospital groups involved in negotiations—the American Hospital Association, the Catholic Health Association, and the Federation of American Hospitals—were assured that should final legislation include a public insurance option, it would pay providers above Medicare and Medicaid rates.

A source close to the negotiations said a deal was struck after discussions about the "shared responsibility" of the entire health-care system—including doctors, insurers, individuals and the government—and an understanding that each part of the system would sacrifice to make it work.

HEALTH CARE: Stopping the Revolving Hospital Door

Joanne Kenen — Tue, 30 Jun 2009 18:45:00 -0400

Not a lot of aspects of U.S. health care still have the power to stun me, but when I first heard the statistics on U.S. hospital readmissions I was, well, stunned. I wrote about readmissions in today's Washington Post (in a collaboration with the new Kaiser Health News.) Readmissions is a pretty sprawling topic, but I think the reason it interested me so much is because it's a nexus of so much of what's wrong with our health care system. Errors of omission and commission. A system so complex and fragmented that we lose track of what the patient needs. Financial penalties (in some although not all cases) for hospitals that try to make things better.

For a Medicare patient who has been hospitalized, about one in five are rehospitalized in 30 days, one in three within 90 days. Within a year, two-thirds are either rehospitalized, or dead. For younger patients, the figures are better but not great. After all, don't we all have friends and family who have gotten out of the hospital and headed right back in again a week, two weeks, a month later?

Not every rehospitalization is unnecessary; people who have excellent care can still have setbacks. Diseases can and do progress. But a lot of these hospitalizations (some experts argue a majority of them) result from patients falling into one crack after another in our chronic care system.

Dozens if not hundreds of projects and initiatives are underway to reduce high readmissions rates. A few lessons have already emerged. For instance, Stephen Jencks, one of the experts I interviewed (he worked for Medicare for a long time and now consults for IHI) told me that one of the biggest factors is whether a patient sees his or her own physician outside the hospital quickly. (Finding out how many don't or can't get an appointment is another stunner). The quality of personal communication is also crucial. The Iowa "Teach Back" program I wrote about sounds so simple, but it actually takes careful effort over several days. The nurses make sure the patient understands what medicine he needs to take when he goes home from the hospital. Easier said than done. Patients who are groggy from their drugs, anxious because they are sick and in the hospital, in too much pain to concentrate or suffering from dementia or short-term memory deficits aren't going to understand complex directions. (Take the little orange pill four times a day on an empty stomach, take the big blue pill three times a day on a full stomach, take the pink pill as needed for pain, take the red pill before the pain starts, avoid grapefruit with the square white pill but have some yogurt to coat your stomach before the oblong white pill, take the little green one to help you sleep but don't take the big green one at night because it will keep you up...Add about a dozen more instructions for an elderly person with several chronic diseases, and call me in the morning). Teach Back is more complex than it sounds at first blush (and it can sound plenty daunting to nurses who are already overburdened by staffing shortages).

Relationships and self-care both seem to matter. The patients at Inova's Heartlink call in their health status, and they have to pay attention to their own bodies—their weight, their breathing, swelling in their limbs. (A relative can take this on if the patient is not well enough or not cognitively able to handle it). But the HeartLink nurse is keeping track. If someone doesn't call in, she notices and she'll check in. Some telephone-based disease management programs have not worked well. The Virginia program I wrote about is new, so their data is still quite preliminary and anecdotal. But it's also very encouraging. It's phone monitoring, but it's phone monitoring with a heart. The HeartLink nurse knows most of the patients in person, or she develops ongoing relationships over the phone. She isn't just a detached voice from out of town. Most of the HeartLink patients are treated by a small cardiology group that works closely with the high quality community hospital. Technically it isn't an "integrated" system, but the relationships—between doctor, nurse, patient and hospital—appear to work.

One last thought. As regular readers of this blog know, I've done a lot of writing on end of life and palliative care. Sometimes we send patients back to the hospital even though they might not really want to be there if their doctor had an honest conversation with them about the severity and likely course of their condition. At some point, even well-managed chronic diseases can become terminal diseases. Instead of going through the revolving door, back into ERs and ICUs, sometimes it is time, as nurse Honora Fowler noted, to have a conversation about palliative care or hospice. It can be hard. But the alternative can be harder.