Are We Appropriately Treating Dying Patients?

We have the best healthcare system in the world for treating patients with serious injury or disease. We don't do so well keeping patients healthier in the first place but that has been covered in a previous post. The problem with out current treatment system is that we do not know how and when to appropriately turn it off and allow a dying patient just to pass on in comfort and peace.

Dr. Martha Twaddle, Chief Medical Officer of the Midwest Palliative and Hospice Care Center in Chicago states that doctors usually know when an illness is incurable yet they continue to practice exhaustive medicine on these patients until there are no treatment options left. It is only when the patient is adamant they they wish to die in peace that the comprehensive arsenal of technology and drugs are withdrawn.

Even though over 80% of patients with progressive chronic illnesses say the want to avoid hospitalization and intensive care when they are dying, most do not get their wish. A study of Medicare patients shows that hospitalizations have risen over the last 10 years for these patients during their last six months of life. They also found that nearly one in three Medicare dollars is spent on patients treating chronic illnesses during their last two years of life.

I think that the suggestion of stopping appropriate medical treatment for a patient with two years life expectancy is going too far. But clearly we can declare patients as hospice candidates earlier than we are doing now. While the number of end of life hospitalizations has increased, the average time spent in hospice has gone down. One in three hospice patients had it for only a week or less when they died. This is a shame because hospice stresses comfort and quality of life which for the incurable is far more important than extending the body's physiological functions with machines.

It will probably be a cost cutting initiative that will reverse this trend rather than doing what is really best for the patient. Either way, we can be proud of our life saving technology and drugs, but lets use them on the lives that can truly be saved.

More on this later.

Mark Brodeur

How Fast Are Hospital Costs Rising? It Depends On What's Treated And Who's Paying

The average cost for treating blood infection septicemia has risen 174% between 2001 and 2007 making it the largest cost increase of any condition and accounting for $12.3 billion in hospital expenditures. But the rate of increase varied significantly depending on who was paying the bill. For uninsured patients the rate of increase was 228%; for Medicare patients it was 172%; and for private insurance patients it was only 152.5%. Considering all the exposure that hospital acquired blood infections have gotten recently as the most preventable type of infection, this does not look good for hospitals. Medicare for one will cease paying for the hospital acquired infections, so I guess the cost increases for these are not significant.

Here are some of the other high rising conditions grouped by payer:

Medicare -Intestinal Infection 205%
-Kidney Failure 154%

Uninsured -Kidney Failure 179%
-Respiratory Failure 154%

Medicaid -Kidney Failure 160%
-Leukemia 127%

Private insurance -Osteoarthritis 120%
-Kidney Failure 119%

Clearly private insurance patients are seeing the lowest cost increases while the uninsured patients are seeing the highest increases. But before we get up in arms about the uninsured being exploited, there are several things to keep in mind. First, these figures do not take into account the huge bad debt percentage from the uninsured population. Second, many of these patients will become insured under healthcare reform. Still it is hard to justify the disparity between payers.

Truly our healthcare reform, at least at this point, is more about payment reform than care delivery reform. But based on the information above, this may be a good place to start.

More on this later.

Mark Brodeur

Quality of Emergency Care Varies Widely Among Hospitals

120,000 additional lives could have been saved if all hospitals in the country operated their Emergency Departments as effectively as the top 5% in the country did. This is according to a new study released by Healthgrades in their first ever Emergency Medicine in American Hospitals Study. This report will now be published annually.

The most disturbing finding of the report is the wide variation that exists between hospitals, both individually and by state. More than 5 million Medicare records of patients admitted to hospitals through Emergency Departments at 4,907 hospitals between 2006 and 2008 were studied. The report focused on mortality rates of patients admitted with one of 11 conditions including bowel obstruction, COPD, diabetic acidosis, heart attack, stroke and pneumonia.

The top 5% of hospitals had a 39% lower risk adjusted mortality rate than the other hospitals. They also showed better improvement in their rates over the two year period than the other hospitals. This is very significant and should motivate all hospital Boards and top management to review their ED performance and focus on improvements.

There were also variations by state with over half of the top 5% coming from just five states: Ohio, Florida, California, Michigan and Illinois. Mississippi, Alabama and Hawaii had the worst overall risk adjusted mortality rates.

The report brought out another interesting fact that one half of all hospital admissions now begin in the ED up from 36% in 1996. For just the 11 conditions studied, Rhode Island, Delaware and Connecticut had the highest percentage of patients admitted through their EDs at 86-89%, while South Dakota, Nebraska and Kansas had the lowest admission rates. Still this makes ED function even more critical to overall hospital operation than it had been in the past. I urge all hospitals to make a serious effort to ensure that they are performing up to the standards of top hospitals. If you would be interested in a free assessment of your ED and how you are functioning compared to benchmarks, feel free to contact us at Compirion Healthcare Solutions at compirion.com.

More on this later.

Mark Brodeur

The Number Of Uninsured Adults Continues To Grow

Healthcare reform with its expanded coverage will come none too soon, but can we afford it. According to the Centers for Disease Control and Prevention, over the last 10 years, the number of adults in this country between 18 and 64 years old without health insurance has increased steadily and is now at 21%. This is an increase of 3 million over the previous year. The obvious cause for the increase, as was discussed in a previous post, is the number of Americans who have lost their jobs or at least lost their health insurance because of the recession.

Correspondingly, the number of adults covered under private health insurance dropped from 68.1% to 65.8% in the last year. This means that roughly 15% of our nation's population, or 46.3 million people do not have health insurance. What will this do to financial projections for the Obama plan for expanded coverage? These projections were shaky at best and certainly seemed underfunded. Its great to think that all of these newly uninsured patients will be getting coverage, but how will it be paid for?

For months in my webinar on healthcare reform I have been saying that much of the funding for this will come from payments to providers, particularly hospitals. My concern in that the hospital's portion of this may have just gotten bigger with the news of more uninsured patients. The financing for this will certainly be worth watching.

There is a little good news in the report though. Coverage for children has actually increased over the last 10 years. This is due primarily to expansions of public plans. But the result is that just over 6 million children (8.2%) are without coverage which is down from almost 10 million (14%) just 10 years ago.

As healthcare reform becomes fully enacted over the next few years, we will see all categories of uninsured patients drop. This is good news as long as we have the financing in place to achieve this without making our most vulnerable hospitals casualties of the reform.

More on this later.

Mark Brodeur

Cutting Medicare Rates To Physicians Is Not The Answer

How long will Congress continue to hang an ax over the heads of physicians threatening to cut Medicare reimbursement? We all know that healthcare costs are rising at a rate much faster than we can afford. We know too that the Medicare system is going broke at the current rate of cost increases. Now we also have the new healthcare reform law greatly expanding government paid coverage to those who have previously been uninsured. It is a perfect storm of financial ruin for publicly funded healthcare. So the answer is cutting rates to physicians? I don't think so.

This is not where we should start, for a number of reasons. First of all the cuts are not focused to address the disparity between primary care physicians and the specialists. Currently specialists can make five times the salary of primary care physicians. There is a shortage of primary care providers now that will continue to get much worse in the near future. Yet the cuts to Medicare will affect these physicians as much as the specialists. If they are truly effective, we will just make our physician shortage worse for the much needed primary care providers.

But will they even be effective? Perhaps HHS should learn from what they did to physicians administering chemotherapy back in 2003. Clearly an inequity in reimbursement had occurred by 2003 and some Oncologists were making record profits from Medicare patients appropriately receiving chemotherapy. Payments were too high so HHS decided to slash reimbursement across the board. The thought was that freestanding, for profit chemotherapy centers run by physicians would close and patients would return to hospital centers who would just eat the losses from these now unprofitable patients. Instead, the Oncologists just changed their orders for chemotherapy to more sophisticated but higher reimbursed drugs, thus increasing the overall cost of chemotherapy to Medicare. Some will argue that this was just a natural shift to newly available drugs. But those close the the situation will acknowledge that oncologists reacted to the reimbursement cuts without compromising the quality of care delivered to patients.

We do need to contain costs and we do need to make our healthcare delivery system more efficient. But this is a complex system that requires complex and comprehensive solutions, not just an arbitrary cut to physician fees.

More on this later.

Mark Brodeur

Quality First: Apparently Not In US Healthcare

Yesterday I commented on patient safety becoming a victim of the recession. Today comes news that The US ranks dead last in healthcare quality when compared with six other industrialized nations. The study comes from a private Washington DC based foundation called The Commonwealth Fund. The major factors leading to this conclusion are the lack of access and equity in healthcare along with the inefficiency of providers.

Currently the US spends the most on healthcare of the countries studied ($7,290 per capita per year) and for this it gets the least of the seven countries. The Netherlands ranked first, spending only $3,837 per capita annually. Karen Davis, the foundation's president, thinks that the new healthcare reform law will improve this ranking when it is fully implemented in 2014. I'm not so sure.

Other nations have improved access through universal coverage and improving the relationship between patients and providers. One of the options they have set up is the development of medical "homes" which are being funded here as trial projects under the reform legislation. But will these be enough to make a significant impact. We seem to have the best system in the world for fixing people who are medically broken, but the worst system for preventing people from getting broken in the first place. The demonstration projects and funding for primary care under healthcare reform just scratch the surface on these issues. Also the improved coverage under reform still leaves 23 million Americans without any healthcare coverage.

By the way, this is not the first time that the US has ranked last on this list. We also came in last in 2007, 2006, and 2004. Also of note, the other countries studied besides the US and the Netherlands are The United Kingdom, Australia, Canada, Germany, and New Zealand.

Quality first and finances follow. Just look at the Netherlands.

More on this later.

Mark Brodeur

The Latest Victim Of Recession: Hospital Safety

For years, hospitals have been considered recession-proof. They have survived during many turbulent economic times in the past. Most people thought that this most recent recession would be no different even though it has been a major one. Well the vulnerability of hospitals to economic distress has finally shown itself according to a new study published in the May/June issue of the Journal of Hospital Medicine. The study was a joint effort by the University of Michigan Health System and the St. Joseph Mercy Health System.

It appears that even though the economy has been terrible for an extended period, relatively few hospitals are closing down. Instead they are all reacting to the economic downturn by laying off staff, halting new construction projects and finding various other ways to improve efficiency and contain costs. Still, more than half of the hospitals in the U.S. reported negative margins in 2008.

All of these hospitals reported decreases in revenue from all sources; patient revenue, investment earnings and donations. Driving the decrease in patient revenue is the fact that many Americans have lost their jobs completely, or at least their health insurance. The number of managed care and private insurance patients has dropped significantly for many hospitals.

When hospitals start losing money on the bottom line, it usually does not bode well for patient safety. Understaffed and under financed hospitals are rarely safe. There certainly are ways for hospitals to improve efficiencies without compromising patient safety. In fact some efficiency efforts can actually improve safety and quality. We at Compirion help hospitals do this every day. But it must be done correctly. Issuing edicts to cut a certain level of costs simply because the bottom line has vanished will not work. There must be a well documented plan based on eliminating wasted efforts and materials, not just on cutting costs. If you need any assistance with this we would be happy to come assess your situation at no cost to you.

Hospital can survive this economic crisis but we must make sure that they do not do so at the expense of patient safety.

More on this later.

Mark Brodeur

Preparing For Our Primary Care Provider Needs

There is very encouraging news from the Director of HHS, Kathleen Sebelius, about investments being made to make sure that we increase the number of primary care providers in years to come. I feel like someone is paying attention and acting before a potential crisis actually develops. We currently have a shortage of primary care providers and the future, particularly with the enactment of healthcare reform, certainly will be much worse. Experts point to several factors that are driving the shortage of primary care physicians. These include poorer reimbursement compared to other specialties, longer working hours, and a shortage of residency spots for training our future physicians.

The new investments to address at least some of these issues were made possible by the Affordable Care Act. These are building on the American Recovery and Reinvestment Act of 2009. Together they will help train and develop more than 16,000 new primary care providers over the next five years. $250 million will be allocated to this effort and will include the following steps:

1) $168 million to create additional primary care residency slots to train more than 500 new primary care physicians by 2015.

2) $32 million to train more than 600 physician assistants who will work under the direction of primary care physicians in the new medical homes thus extending the number of patients that can be seen by these physicians.

3) $30 million to encourage over 600 nursing students to pursue school full time.

4) $15 million for the operation of 10 nurse practitioner led clinics located in medically underserved areas that will also assist in the training of future nurse practitioners.

5) $5 million for states to develop innovative ways to encourage additional primary care providers in their state.

These steps don't exactly address the issue of paying primary care physicians more in relation to other specialties but they do start to address lifestyle issues and directly address an increase in training slots for future providers. I applaud the HHS Secretary on this announcement and hope to see additional efforts in this area.

More on this later.

Mark Brodeur

Healthcare Reform: The Good, The Bad, and The Ugly (Part 3)

I spent the last two posts talking about the good and then the bad aspects of the new healthcare reform bill. I want to close this discussion today by addressing the significant changes ahead which can be viewed as opportunities or, more realistically, challenges. These challenges may not truly be ugly, but they will certainly require that hospitals adjust how they do business. Changes extend beyond the delivery system to concern tax exempt status and pricing transparency.

First the delivery system changes. We have long complained that the current system rewards volume and not outcomes. Well both Medicare and Medicaid are now shifting to value based payment systems. Unfortunately the approach will be largely punitive such as not reimbursing for readmissions or hospital acquired conditions rather than rewarding true high value providers. Also, as the system goes forward, hospital payments will be initially withheld and then released only after the hospital shows quality improvements from the prior year or attains defined quality benchmarks. By FY2013, hospitals with higher than expected readmission rates for certain diagnoses will have their payments reduced substantially. CMS expects this alone to save them over $7.1 billion over a ten year period. By FY2015, the same thing will apply to hospital acquired conditions.

The intent is to radically reshape the healthcare delivery system. There will be pilot programs to test bundled payments to providers and create accountable care organizations both of which are intended to promote further collaboration between physicians and hospitals. Again, this would be a positive development if the payment approach was not strictly punitive in nature.

Hospitals need to be aware that their tax exempt status will continue to be challenged under the new legislation. It will require them to conduct a community needs assessment and report annually on their actions to address these needs including reaching out to charity care patients. There must be a publicized a financial assistance policy which meets federal requirements and collection efforts can only proceed after reasonable efforts to see if the patient qualifies for charity care.

In closing, it is imperative that hospital be prepared for the changes coming. First of all they need to understand the legislation. These three posts only scratch the surface of the legislation. As you wade through the pages and pages of change, you will see that some of it is good, some bad and some downright ugly.

More on this later.

Mark Brodeur

Healthcare Reform: The Good, The Bad, and The Ugly (Part 2)

Yesterday I covered some of the positive aspects of the new healthcare reform legislation. Yes, there are some. Today let's take a look at some of the more troublesome points in the new plan. This could probable become a very exhaustive list, but I will choose to stick with the highlights (or perhaps more accurately, the lowlights). These include the obvious payment cuts to help finance the expanded system and the employer "free rider" penalty which will cut into hospital bottom lines.

About half of the new healthcare reform legislation's cost, estimated to be $938 billion, will be financed through savings coming from the current healthcare system. These savings will largely be generated by just cutting reimbursement for existing services. Hospitals are expected to shoulder about $149 billion in cuts to market basket updates and disproportionate share hospital (DSH) payments. Hospitals will also be ultimately affected indirectly by the cuts being made to other related industries such as health insurers, pharmaceutical manufacturers and device companies.

In making these cuts there is the assumption that hospitals are being run inefficiently and that through there own initiatives, hospitals will be able to become far more productive and thus sustain the cuts with no damage to their bottom line. I have no doubt that most hospitals can become a bit more efficient. We at Compirion Healthcare Solutions assist hospitals with this effort every day. But to base the financing of this huge initiative on a general assumption like this without knowledge of the impact this will have on struggling but critically necessary hospitals is irresponsible.

To make matters worse, the cuts to DSH payments are based on another assumption that many of the current payments are not justified based solely on the cost of providing indigent care. Also that these costs will go down when coverage is expanded. I don't know of many high DSH hospitals that are making record profits like some of the insurance companies or pharmaceutical manufacturers. Is this really the right place to cut?

Finally hospitals need to consider the impact of the free rider penalty they may face as an employer. Hospitals as a service industry are labor intensive and healthcare insurance costs are a major expense to the bottom line. Any employer, including hospitals, with 50 of more employees that offers a qualified health plan and contributes any portion to the premium must also provide a free choice voucher equal to the employee's premium contribution. The employee can then use this voucher to purchase insurance in a state exchange. If the hospital plan does not meet all requirements they are subject to a free rider penalty. If this sounds confusing, it is. But hospitals need to be aware of their financial liability.

So much for the bad in the news healthcare reform at least for this go around. I am sure that more will come out later. Tomorrow I will discuss the significant system reforms (the ugly) that will be occuring.

More on this later.

Mark Brodeur

Healthcare Reform: The Good, The Bad, and The Ugly (Part 1)

Most of my colleagues are dreading the full implementation of the new healthcare reform law and hoping that the Republican surge expected in elections this November will lead to blockage of most reform measures before they start. A few CEOs with higher Medicaid populations are quietly rooting for President Obama and expecting some positive developments. The truth is that there are some elements of the new bill that will be good for many hospitals, some that will be bad for most hospitals and some that will change things forever. Maybe ugly is too strong a word for this last category.

Let's start with the good. Provisions such as changes to insurance markets, malpractice reform demonstrations and funding to help hospitals with high volumes of preventable readmissions will help hospitals grow revenue while reducing costs. That is any hospital's quick formula for success. Let's look a little deeper at these.

Insurance coverage will be expanded to 32 million people who do not currently have insurance and mostly fall in hospitals' bad debt and charity categories. This expansion of coverage will occur by increasing regulatory oversight of commercial insurers, using tax codes and subsidies to mandate coverage, and creating state based exchanges to improve accessibility, transparency and efficiency of insurance markets. This last step of state based agencies is already off to a bad start with most states declining the option to run their own programs and instead letting federal programs operate in their states for this purpose. It appears that this aspect of healthcare reform is grossly underfunded. We will wait and see how overall funding for the additional coverage works out.

With Democrats controlling all aspect of the new healthcare reform law, no one expected it to include any sweeping malpractice reform which if done right could save many billions. But it does include $50 million over five years for malpractice demonstration projects. The money will be used to explore alternative methods to resolve medical liability claims, such as health courts and early offer programs. Its not a lot but at least its a start.

Facilities fighting high readmission rates will be able to join a five year Medicare pilot program to reduce them. The program starts next year and gives priority to small community hospitals and those with high undeserved populations. Hospitals will be paid to intervene on patients who are at high risk for readmission using tools such as comprehensive medication reconciliation at discharge. I certainly appreciate this approach over the current mentality of just denying hospitals payment for readmissions regardless of the cause. Reimbursing someone to prevent readmission makes a lot more sense.

This is pretty much it for the good. The next two days I will talk about the bad and the ugly.

More on this later.

Mark Brodeur

What Happened To The Personal Responsibility For Our Own Healthcare?

We all have some personal practices that may put our health at some degree of risk, things like overeating, smoking, alcohol consumption, high stress jobs, etc. Some people take that risk to unreasonable levels resulting eventually in a medical catastrophe. For some it is lifestyle and upbringing that brings out this behavior. For others it is physical addiction. But for some it is a financially driven decision.

I just read two studies that each in their own way amaze me about human behavior and the influence of money. In the first, it was discovered that by paying noncompliant patients to take the medicines that were prescribed for them, they suddenly became more compliant. Keep in mind that these patients had some significant medical problems resulting from not taking their prescriptions regularly. Apparently they were ok with that. To make matters worse, after a period of payment, this incentive was removed. The result was that patients regressed back to "forgetting" to take their meds. What is going on here? As we move forward with healthcare reform and treating these non compliant patients' eventual acute crises becomes our financial responsibility, we should have a say in their behavioral choices. Perhaps there should be some measure of personal responsibility demonstrated in order to qualify for unlimited healthcare coverage.

The second study states that last year over 2 million cancer survivors did not get needed medical services because of concerns over the cost of care. This represents 18% of all U.S. cancer survivors. Some of the care avoided was not directly related to cancer treatments but most of it was. This behavior may be a little more understandable than the first study where patients already had access to drugs and just chose not to take them. Still, once a diagnosis of cancer is given, I would think that patients would make treatment their first financial priority. In these patients, a more liberal healthcare coverage plan certainly should have a positive impact. I would hope that removing financial concerns would improve their compliance significantly.

Healthcare coverage should be expanded to all those who need it. But as we do this, each of us also carries a personal responsibility for at least a level of good health practices. If you choose not to take medications that are prescribed and given to you, we as a society should not be responsible for the cost of your ultimate medical crisis. At least that is my opinion.

More on this later.

Mark Brodeur

Good News, Bad News For Healthcare Acquired Infections

On the heels of last week's encouraging report that hospital acquired infections (HAI's), especially blood stream infections, are decreasing, comes the not so good news that infection control practices in many Ambulatory Surgical Centers (ASC's) are substandard. In a study of ASC's in three states, two thirds showed lapses in infection control practices that put patients at higher risks.

The proliferation of these centers driven by financial incentives to the investors, has caused a significant number of minor surgeries to move from hospital settings to freestanding centers. In many cases these centers provide a greater level of convenience for the patients and sometimes cheaper out of pocket expenses. Meanwhile physicians enjoy more productive days because of faster turnaround times as well a generous return on their investment. This is all well and good as long as patient safety is given the same priority as hospital based surgical centers and quality measures are not compromised.

In light of this study, Kathleen Sebelius was quick to respond with the HHS Action Plan To Prevent Healthcare Associated Infections. She stated that ensuring the safety of patients in all healthcare settings was the top priority for HHS. That's why $50 million dollars in funding from the American Recovery and Reinvestment Act is being allocated to prevent HAI's. Of that, $10 million will be spent on improved processes and increased frequency of inspections for ASC's. Also the Affordable Healthcare Act calls for improvements in healthcare quality and reduced HAI's. Further, she states that just because procedures are being done outside the hospital setting does not mean that patient safety standards and infection control measures are any less important.

I applaud the HHS Secretary for her strong stand and fully support her efforts to demand compliance from freestanding surgery centers, not just because it keeps a level playing field with hospitals but most importantly because it maintains protection for our patients.

More on this later.

Mark Brodeur

A Warning For Healthcare Providers: Don't Share Patient Info On The Web

Social networks such as Facebook have revolutionized how many of us, especially the younger crowd, interact and share information. This can have many positive effects drawing people together who had previously lost all contact. But it also has a negative side. We have already seen the cyber-bullying cases. Now comes a new problem; nurses and other providers sharing stories about patients on their Facebook page.

At least five employees at Tri City Medical Center in California will most likely be losing their jobs because of postings they made to Facebook talking about patients they cared for. Although no names or ID numbers were used, the postings appear to be a a clear HIPAA violation according to sources at the hospital. The nurses involved claim that they only posted hypothetical patient scenarios to discuss with other nurses for educational purposes. Hospital officials contend that the information posted was about actual patients and for the purposes of gossip.

This case merits a warning to all healthcare providers that they keep all patient information confidential, particularly when posting on a public, or at least semi-public website. I would like to think that there are never any inappropriate discussions about patients, but I'm sure that sharing this kind of information among colleagues is not new. The problem is that leaving written information on a website forces the hand of the hospital to take action.

Let's take our patient's rights seriously and leave Facebook for connecting with friends.

More on this later.

Mark Brodeur

Creating A Culture Of Patient Safety: The Role Of Medical Schools

As hospitals today try to build a culture of Patient Safety, everyone looks to the CEO to lead this change and integrate patient safety as every body's primary concern. And this is how it should be. But this alone will not build the desired culture. There are many other providers and support personnel who must also be part of this new culture. So how do we ensure that all of the physicians are part of this process? It would be helpful if this were part of their basic training in medical school, but sadly this is not the case.

Rather than teaching future doctors about patient safety, teamwork and how to learn from their mistakes, medical schools throughout the U.S. continue to focus myopically on basic science and clinical knowledge. This is the conclusion of the Lucian Leape Institute at the National Patient Safety Foundation. They state that medical schools and teaching hospital leaders should place the highest priority on creating learning cultures that emphasize patient safety, model professionalism, enhance collaborative behavior, encourage transparency, and value the individual learner.

Another report put together by a 40 member roundtable of medical students, medical educators and leaders in patient safety concluded that effective interpersonal skills and the science of improvement can be just as important as the basic concepts that have been taught in medical schools for generations. They conclude that each physician that grasps the multiple dimensions of patient safety is one more physician likely to find humility in the challenge and therefore likely to provide safe care to his or her patients. More importantly, such a physician is far more likely to lead the development of positive organizational cultures and patient safety priorities.

Besides biochemistry, let's teach our future physicians what a patient safety culture really means.

More on this later.

Mark Brodeur

Who Is Responsible For The Abandoned Medicaid Paitients?

As we gear up to significantly expand the ranks of Medicaid patients under the new healthcare reform law, perhaps we should take a look at some of the issues that have not been resolved under the current program before we make them even bigger. One of the most significant issues is taking care of the debilitated low income Medicaid patients that need rather intensive extended care. Nursing homes reject hundreds of these patients claiming that they are unable to safely meet the patient's needs. The real reason, recently reported on by the Seattle Times, is much more sinister. These patients require more services and are definitely money losers for the nursing homes.

Their answer is to dump them off on hospitals. I have certainly seen this throughout my career. Normally the call from the nursing home comes in the evening or on the weekend when the hospital's regular crew of preadmission screeners are not on duty. Or the patient may simply show up in the Emergency Department straight from the nursing home. Once they are admitted to the hospital as an inpatient and the acute condition is fully treated, suddenly they do not meet criteria to return to the nursing home they came from. These kinds of patients are known throughout the community and soon none of the nursing homes will take them. Again, as with many other components of our uneven healthcare system, it falls upon the hospital to eat the cost of care for these patients.

I have not seen anything in the new healthcare plan that addresses these patients. As Medicaid coverage extends to more indigent patients who are currently uninsured, the numbers of these "in-between" patients will certainly grow. I don't condemn the nursing homes who are struggling in their own right to stay afloat with underfunded Medicaid payments. But abandoning them on hospital doorsteps is not the answer either.

Let's work this issue out before making our problems bigger with an expanded system.

More on this later.

Mark Brodeur

"Never Events" Still On The Rise In California

With all of the efforts hospitals have put into quality improvement and patient safety, it is discouraging indeed to read a report like the one issued recently by the California Department of Public Health. The report highlighted that "never events", particularly leaving foreign objects in patients following surgery, are on the rise. Last year California hospitals reported 197 cases of retained foreign objects which brought the two year total to 350. That's 14% of all the preventable errors reported during that two year period.

What's going on with these hospitals? I understand that we are dealing with a complex situation that is run by humans who are prone to error, but where are the checks and double checks in the procedure to account for the possibility of error? San Francisco General Hospital after being fined by the state for leaving a surgical sponge in a patient, has now changed its policies to significantly reduce the likelihood of this happening again. Good for them, but why did it take a fine to motivate them to do something that should have been done long before this?

There are high tech solutions being applied to this such as bar codes and radio frequency detection systems, but it still boils down to checks and double checks of all instruments, pads and sponges used during a procedure. There is no single solution that can be universally applied to all hospitals. It is human nature that after years of double checks that never find a missing sponge to get lax and not catch the one that finally happens.

Penalties and fines are not the answer to change culture. Facing public exposure of such errors is probably a stronger deterrent. But building a culture of patients first is the only real way to address this issue. Because we are human, we probably can't keep this number at zero. But we can sure do a darn sight better than we saw last year in California.

More on this later.

Mark Brodeur

Hospitals Still Struggle With Providers Washing Their Hands

It seems very basic doesn't it? Providers need to wash their hands before and after interacting with patients. Every care provider knows this as well as the potential risks to patients and themselves for not following guidelines. So why is this so hard to do? I'm not sure why but I know that it is still an issue.

In the May issue of Applied Nursing Research a study of 67 providers who were followed over a course of 16 weeks showed them to be compliant with handwashing guidelines only 34% of the time. Doctors were more compliant washing their hands after procedures rather than before (72% vs 42%). This suggests that they are far more interested in protecting themselves rather than their patients. Almost all hospitals have gel dispensers either inside or just outside every patient room. What will it take to get providers to use them?

We at Compirion have helped hospitals address this issue. At Bay Medical Center in Florida the handwashing compliance was about 25%, even worse than this recent study. Like most hospitals we see, it had fallen to Infection Control to be the handwashing police. But they could not have a large enough presence to obtain good compliance. So we helped them create a Steering Team to address this issue. It had widespread, across the board involvement from the CEO down to housekeeping. With this kind of attention, behaviors changed rapidly. Their compliance rose to the 90% range and has remained there after the initial push.

By the way, their overall hospital mortality rate dropped from 3.4 to 2.1 during this period. Was this simply coincidence? According to MedPage Today, there are over 90,000 deaths a year from healthcare related infections and additional costs of $5-6 billion to treat them.

Excuse me, I have to go wash my hands.

More on this later.

Mark Brodeur

Who Coordinates Care For Discharged Patients?

With our current patchwork system of independent providers that includes primary care physicians, specialists, hospitals, home care providers and a host of support services, sometimes the communication between them is lost. When this happens, the patient who is dependent on the coordination of all these services is the one who suffers. This gap seems to be most evident for the newly discharged patient who still must follow a regimen of medication and/or treatment following discharge from the hospital. Where does the hospital's responsibility stop and the primary care physician's responsibility resume? Or is it the job of the specialist? As lengths of stay get shorter and we handle more care on an outpatient basis, this becomes an even bigger issue.

A recent study in the Journal of the American Medical Association highlights this issue relative to heart failure patients. They found that post discharge death rates and readmissions have increased for these patients between 1993 and 2006. At the same time, length of hospital stay has decreased by 2.5 days from 8.8 to 6.3. The study was not conclusive that the shorter length of stay caused the increase in either deaths or readmissions. There may have been other outside factors involved. But the point is that we have a gap in our healthcare system and it seems to be getting worse.

The popular response to this seems to be that we hold the hospital responsible. First we incentivize them to shorten length of stay because we assume they are keeping patients unnecessarily long then we deny payment for readmissions because we assume they are now discharging patients way too early. The fact is that there are many factors that contribute to a patient's readmission. Many of the are out of the control of the hospital. Some of them are out of the control of any of the providers. I have discussed this issue in more detail in a previous post.

The answer is that it involves more than just the hospital. All providers and the patients themselves play a role in this. The key is to have a system where all providers and the patients are involved in their post discharge treatment plan. There are some models being developed as part of the new healthcare reform that show promise for addressing this issue. Let's hope they work.

More on this later.

Mark Brodeur

Decrease in Central Line Infections Saves Lives (And Money)

Quality first and finances follow. That is my mantra because it keeps demonstrating itself over and over in healthcare. The latest example is the Ceneters for Disease Control and Prevention report that central line infections are down over 18% from the previous three years across the country. This is a victory in two respects. First getting the information at all has been a challenge. Remember, if you can't measure it you can't manage it. Second, the fact that we are seeing a significant drop of this magnitude is statistically significant.

There was a feeling for years that hospitals were tracking their infection rates and keeping them secret because they were ashamed of the results. But the truth for many institutions was even worse. They were not tracking them at all. Now that these hospitals have been forced to measure this they have also been forced to manage it and we are seeing the results of these efforts.

It is estimated that there are 1.7 million hospital associated infections each year which claim 100,000 lives and add $30 billion in healthcare costs for treatment. Among these, blood stream infections are the most preventable. The recent drop in them must be attributed to the fact that hospitals must now report these numbers and are therefore more strictly adhere to CDC guidelines.

The good news is that lives are being saved and as a bonus, hospitals are saving money on the treatment costs of preventable infections. Looks like a win-win scenario.

More on this later.

Mark Brodeur