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
Tuesday, June 1, 2010
Thursday, May 27, 2010
Another Patient Safety Tip: Avoid Physician Interruptions
I recently shared a study that showed how nurses who were interrupted repeatedly during medication administration were far more likely to commit medication errors. Now comes another study published online by Quality and Safety in Healthcare that shows similar outcomes with physicians. Although this one has a slightly different twist. It seems that physicians who get frequently interrupted fall behind on their tight schedule and therefor cut corners to help make up for lost time. This behavior was shown to have put some patients at higher risk.
The study was conducted at the University of Sydney in Australia and covered 40 physicians at a 400 bed hospital. They found that physicians were interrupted an average of 6.6 times per hour. Once interrupted, physicians either completed tasks in a much shorter time frame than they should have or skipped completing the task completely. Tasks interrupted 3 times or more that had a predicted completion time of 23 minutes were finished in just over 6 minutes following interruptions. One method employed frequently by the physicians was multitasking.
The good news is that only about 11% of the physician's tasks were interrupted one or more times. But as the author notes, "interruptions add significantly to cognitive load, increase stress and anxiety, inhibit decision-making performance and increase task errors. Unlike the nurse study, this one did not look at the necessity of the interruptions. But it can be safely assumed that many of the interruptions can be avoided.
Let's leave our doctors, and nurses, alone when they are deeply involved in patient care.
More on this later.
Mark Brodeur
The study was conducted at the University of Sydney in Australia and covered 40 physicians at a 400 bed hospital. They found that physicians were interrupted an average of 6.6 times per hour. Once interrupted, physicians either completed tasks in a much shorter time frame than they should have or skipped completing the task completely. Tasks interrupted 3 times or more that had a predicted completion time of 23 minutes were finished in just over 6 minutes following interruptions. One method employed frequently by the physicians was multitasking.
The good news is that only about 11% of the physician's tasks were interrupted one or more times. But as the author notes, "interruptions add significantly to cognitive load, increase stress and anxiety, inhibit decision-making performance and increase task errors. Unlike the nurse study, this one did not look at the necessity of the interruptions. But it can be safely assumed that many of the interruptions can be avoided.
Let's leave our doctors, and nurses, alone when they are deeply involved in patient care.
Mark Brodeur
Wednesday, May 26, 2010
Hospital Closures Create a Crisis In Queens
Yesterday I talked about the ultimate impact of reimbursement cuts to hospitals saying that this could lead to closures. The Wall Street Journal on Monday ran a scary article about how this is already happening in the borough of Queens in New York City. In the last two years, three hospitals have closed in Queens decreasing its bed capacity by almost a third and giving it the lowest ratio of beds per 1000 population in the area (1/3 of Manhattan's capacity). One hospital closed at the request of a state commission and the other two just went bankrupt.
How has this affected healthcare? At New York Hospital Queens, patients are waiting an average of 17 hours to be placed in beds. At Jamaica Hospital Medical Center, the Emergency Department has been expanded into a former cafe and conference room to try and cope with the huge growth in new patients. The ED there was designed for a maximum of 60,000 patients a year and they are currently seeing over twice that. At Compirion we offer excellent assistance to hospitals preparing for surges, but dealing with this type of situation would be a challenge.
Patients at these hospitals describe the situation as being in a war torn third world country. Sometimes ambulances need to park outside the ED with their patients waiting for their turn to get in the hospital. Hallways are filled with gurneys. ED nurses see up to 28 patients during a 12 hour shift. Requesting that ambulances go on diversion doesn't do any good because every other hospital is on diversion too.
Some patients are avoiding this chaos by traveling to other boroughs for healthcare. But what happens when these hospitals face the same extreme measures? To reiterate what I said yesterday, simply cutting payments to hospitals will not solve our current crisis. Continued cuts will just spread the situation in Queens to the rest of the country. We need a coordinated effort to address all of the areas of inefficiency, payment inequities and abuses of the system.
More on this later.
Mark Brodeur
How has this affected healthcare? At New York Hospital Queens, patients are waiting an average of 17 hours to be placed in beds. At Jamaica Hospital Medical Center, the Emergency Department has been expanded into a former cafe and conference room to try and cope with the huge growth in new patients. The ED there was designed for a maximum of 60,000 patients a year and they are currently seeing over twice that. At Compirion we offer excellent assistance to hospitals preparing for surges, but dealing with this type of situation would be a challenge.
Patients at these hospitals describe the situation as being in a war torn third world country. Sometimes ambulances need to park outside the ED with their patients waiting for their turn to get in the hospital. Hallways are filled with gurneys. ED nurses see up to 28 patients during a 12 hour shift. Requesting that ambulances go on diversion doesn't do any good because every other hospital is on diversion too.
Some patients are avoiding this chaos by traveling to other boroughs for healthcare. But what happens when these hospitals face the same extreme measures? To reiterate what I said yesterday, simply cutting payments to hospitals will not solve our current crisis. Continued cuts will just spread the situation in Queens to the rest of the country. We need a coordinated effort to address all of the areas of inefficiency, payment inequities and abuses of the system.
Mark Brodeur
Tuesday, May 25, 2010
Rate Freezes, Even Cuts Are Expected At Many Hospitals
The future for hospital reimbursement appears to be every bit a s bad as people had projected. Massachusetts health insurers have announced that they want to freeze or slash payments to some hospitals and physician groups this year, thus setting up the most contentious negotiating atmosphere we have seen in years. Why are things different? Because insurers are confident that they have the sympathy of politicians, regulators and employers.
Healthcare costs are rising out of control and the simplest answer appears to be just pay hospitals less. That answer may be easy but it is not going to solve the problem. Two thirds of hospitals in the country already lose money under Medicare. State Medicaid programs are worse. And managed care companies have long ago stopped any cost shifting in their direction.
So how will this play out? Certainly not well for most hospitals and ultimately not well for many patients. Yes, a number of hospitals can get themselves more efficient and shave some costs. But these are not the big dollars of waste in the system. Lynn Nicholas, President of the Massachusetts Hospital Association thinks this will ultimately lead to layoffs, mergers and closures for some hospitals in the state.
Massachusetts has been the bell weather for many trends in healthcare. This looks like another opportunity to see what will soon be happening around the country. Have some powerful systems used their clout over the years to force some favorable reimbursement? Quite possibly. But to take the approach that healthcare saving can be had simply by cutting rates to the average hospital without consequences is not well thought out. Let's tackle some of the areas with real waste and lets start with tort reform legislation.
More on this later.
Mark Brodeur
Healthcare costs are rising out of control and the simplest answer appears to be just pay hospitals less. That answer may be easy but it is not going to solve the problem. Two thirds of hospitals in the country already lose money under Medicare. State Medicaid programs are worse. And managed care companies have long ago stopped any cost shifting in their direction.
So how will this play out? Certainly not well for most hospitals and ultimately not well for many patients. Yes, a number of hospitals can get themselves more efficient and shave some costs. But these are not the big dollars of waste in the system. Lynn Nicholas, President of the Massachusetts Hospital Association thinks this will ultimately lead to layoffs, mergers and closures for some hospitals in the state.
Massachusetts has been the bell weather for many trends in healthcare. This looks like another opportunity to see what will soon be happening around the country. Have some powerful systems used their clout over the years to force some favorable reimbursement? Quite possibly. But to take the approach that healthcare saving can be had simply by cutting rates to the average hospital without consequences is not well thought out. Let's tackle some of the areas with real waste and lets start with tort reform legislation.
Mark Brodeur
Monday, May 24, 2010
High Tech Devices May Assist Effectiveness of Healthcare Reform
One of the major goals of healthcare reform is to promote prevention, early diagnosis and primary care intervention for the greatest part of the population currently living unhealthy lifestyles. A significant obstacle to this has been the reluctance of patients to follow up on physician suggestions for testing and treatment usually done at hospitals. And even if they start now that they will have insurance coverage, the costs to the system will be significant.
New technology may soon be providing solutions to both of these issues. Soon many diagnostic capabilities that have been only done in hospitals may be available in physician offices or even patient homes. The combination of new lower cost computing devices, digital sensors and the web are making diagnosing and monitoring patients far more accessible.
Healthcare reform is pushing the development of primary care alternatives like medical homes to be more available to patients. The problem has been that accurate diagnosis and monitoring of the patients condition have relied on patient followup to hospital based or other freestanding modalities. What if all of these modalities could be available in the medical home with monitoring devices sent home with the patient?
This is not far off. Consider the case of sleep studies. Up to this point to conduct a worthwhile sleep study has required that the patient spend the night in a hospital based or freestanding facility in a strange environment hooked up with wires coming from everywhere. This is how we expect to study the patients normal sleep patterns. The inconvenience and intimidation of this test keeps many patients away until symptoms are severe. Also the cost of this test can be as much as $4,000.
Watermark has now developed a device that is smaller than a deck of cards and worn on the patient's forehead held on by a headband. There is a tube which runs to the patient's nose. The patients wears this at home for a night or two then the information that it gathered is sent via web to a sleep disorder specialist who returns a diagnosis within 48 hours. Total cost is well under half of a conventional sleep study.
As more diagnostic modalities like this one are developed. We can truly make diagnosis and monitoring of patients far more accessible. Cost savings will come not just from the testing itself but also from keeping these patients conditions in check thus avoiding costly hospitalizations.
More on this later.
Mark Brodeur
New technology may soon be providing solutions to both of these issues. Soon many diagnostic capabilities that have been only done in hospitals may be available in physician offices or even patient homes. The combination of new lower cost computing devices, digital sensors and the web are making diagnosing and monitoring patients far more accessible.
Healthcare reform is pushing the development of primary care alternatives like medical homes to be more available to patients. The problem has been that accurate diagnosis and monitoring of the patients condition have relied on patient followup to hospital based or other freestanding modalities. What if all of these modalities could be available in the medical home with monitoring devices sent home with the patient?
This is not far off. Consider the case of sleep studies. Up to this point to conduct a worthwhile sleep study has required that the patient spend the night in a hospital based or freestanding facility in a strange environment hooked up with wires coming from everywhere. This is how we expect to study the patients normal sleep patterns. The inconvenience and intimidation of this test keeps many patients away until symptoms are severe. Also the cost of this test can be as much as $4,000.
Watermark has now developed a device that is smaller than a deck of cards and worn on the patient's forehead held on by a headband. There is a tube which runs to the patient's nose. The patients wears this at home for a night or two then the information that it gathered is sent via web to a sleep disorder specialist who returns a diagnosis within 48 hours. Total cost is well under half of a conventional sleep study.
As more diagnostic modalities like this one are developed. We can truly make diagnosis and monitoring of patients far more accessible. Cost savings will come not just from the testing itself but also from keeping these patients conditions in check thus avoiding costly hospitalizations.
Mark Brodeur
Friday, May 21, 2010
Interesting Study On ED Overuse By Medicaid vs Uninsured Patients
Earlier this week I discussed the need to prepare for the onslaught of new patients who will suddenly have insurance coverage. The plan is that they will immediately start using available primary care resources but the reality is that they will continue using the Emergency Department as their primary care provider unless we all take action to redirect this behavior.
A new data brief from the Centers for Disease Control and Prevention presents interesting information that indirectly supports this concern. Their study dismisses the longstanding belief that uninsured patients use the ED much more than privately insured patients. It turns out this is not true which comes as somewhat of a surprise to me. ED use by uninsured patients is only a few percentage points higher than privately insured patients. But Medicaid patients (who would be uninsured without this program) have much higher ED use rates. Medicaid patients in the 45-60 year old range had more than double the ED use rate of other patients. 18-44 year old Medicaid patients also had significantly higher use rates.
On one hand it is surprising to learn that uninsured patients do not necessarily overuse EDs as a primary care provider. On the other hand is is disappointing that patients who have had access to insurance, albeit Medicaid, have continued to use the ED as their entry into the medical system rather than establishing a relationship with a true primary care provider. This just reinforces the fact that we have a lot of work to do in terms of education and accessibility of primary care resources if we want to prevent our EDs from beings overrun with newly insured patients.
I think that Dr. Brokaw's points that I discussed earlier this week are all very valid and this study just reinforces the fact that we need to be proactive in this area.
More on this later.
Mark Brodeur
A new data brief from the Centers for Disease Control and Prevention presents interesting information that indirectly supports this concern. Their study dismisses the longstanding belief that uninsured patients use the ED much more than privately insured patients. It turns out this is not true which comes as somewhat of a surprise to me. ED use by uninsured patients is only a few percentage points higher than privately insured patients. But Medicaid patients (who would be uninsured without this program) have much higher ED use rates. Medicaid patients in the 45-60 year old range had more than double the ED use rate of other patients. 18-44 year old Medicaid patients also had significantly higher use rates.
On one hand it is surprising to learn that uninsured patients do not necessarily overuse EDs as a primary care provider. On the other hand is is disappointing that patients who have had access to insurance, albeit Medicaid, have continued to use the ED as their entry into the medical system rather than establishing a relationship with a true primary care provider. This just reinforces the fact that we have a lot of work to do in terms of education and accessibility of primary care resources if we want to prevent our EDs from beings overrun with newly insured patients.
I think that Dr. Brokaw's points that I discussed earlier this week are all very valid and this study just reinforces the fact that we need to be proactive in this area.
Mark Brodeur
Thursday, May 20, 2010
Hospital Patient Satisfaction Scores Fall To Six Year Low
If you have seen the Patient Satisfaction scores at your hospital dip, you are not alone. According to the American Consumer Satisfaction Index (ACSI) hospital patients are unhappier than they have been in six years. The average score is 73 out of 100. Emergency Departments have fared even worse with an average score of 54 out of 100. The only area showing an increase was Ambulatory Care which rose 1% to 81.
This is obviously bad news for everyone except for consultants like us here at Compirion who make a living helping hospitals improve metrics such as Customer Service scores. In this current climate of consumer driven healthcare and demand for high value hospitals it is particularly important that hospitals satisfy their patients. Exceeding expectations is not just a trite motto but a necessary business strategy for survival. Simply put; satisfying patients leads to growth in new business.
Perhaps you can look at the current drop in customer service scores as a business opportunity to get a jump on the competition. Something is happening across the nation. Emergency Departments saw a 12% dip in satisfaction scores for the first quarter of this year. They drug overall hospital scores down 5% with them. This is just more proof of how vitally important the ED's reputation is on the entire hospital.
By the way, we can't blame the dip on a sour economy that just has people upset in general. According to ACSI, energy was the only other industry besides healthcare to see a drop. All others have seen increases. The report does not explain why there has been such a drop and I must confess that I am at a loss to explain this as well. I invite anyone with a perspective on this to please share their opinions. From my viewpoint, hospitals are focusing on this now more than they ever have before. If you have not done so yet, now is a golden opportunity.
More on this later.
Mark Brodeur
This is obviously bad news for everyone except for consultants like us here at Compirion who make a living helping hospitals improve metrics such as Customer Service scores. In this current climate of consumer driven healthcare and demand for high value hospitals it is particularly important that hospitals satisfy their patients. Exceeding expectations is not just a trite motto but a necessary business strategy for survival. Simply put; satisfying patients leads to growth in new business.
Perhaps you can look at the current drop in customer service scores as a business opportunity to get a jump on the competition. Something is happening across the nation. Emergency Departments saw a 12% dip in satisfaction scores for the first quarter of this year. They drug overall hospital scores down 5% with them. This is just more proof of how vitally important the ED's reputation is on the entire hospital.
By the way, we can't blame the dip on a sour economy that just has people upset in general. According to ACSI, energy was the only other industry besides healthcare to see a drop. All others have seen increases. The report does not explain why there has been such a drop and I must confess that I am at a loss to explain this as well. I invite anyone with a perspective on this to please share their opinions. From my viewpoint, hospitals are focusing on this now more than they ever have before. If you have not done so yet, now is a golden opportunity.
Mark Brodeur
Wednesday, May 19, 2010
Four Steps Necessary To Keep Non Emergency Patients From Using the ED
With the passage of healthcare reform and coverage being provided to many folks who have been uninsured for years, it is assumed that they will now seek primary care and not inappropriately use Emergency Departments. This may happen over time but will not occur by itself. In fact, based on what happened in Massachusetts some years ago when insurance coverage suddenly became available to many who did not have it before, quite the opposite happened. Patients were used to going to the ED for primary care and minor issues. Now that they had insurance coverage they were even more prone to visit the ED.
This is a terrible way to deliver this kind of care for a number of reasons. First and foremost it is extremely expensive. A typical ED visit costs about 5 times what a clinic visit would cost. Secondly the care in an ED is episodic. The ED physician has no established relationship to the patient and no history to work from. This often leads to overtreatment and rediagnosing established chronic conditions of the patient.
So as we prepare for the addition of many new patients who will have insurance coverage for the first time, it is important that we take steps ahead of time to ensure that that are treated in the appropriate setting. We can not sit back and expect that this will happen by itself. The Washington Post recently published an article written by a San Francisco ED physician, Dr. Jennifer Brokaw, who lists 4 steps that should be occurring now.
1) Establish more offices, clinics and urgent care centers, particularly in medically indigent areas.
2) Invest in more allied health professionals and physician extenders. It is clear that we will not have a sufficient number of primary care physicians. We need to be ready to delegate some of this works to others.
3) Start coordinating the various delivery systems that currently do not communicate with each other. We know a great surge in demand is coming. Providers need to work together to make sure the supply of providers and support modalities is adequate.
4) Take advantage of the internet and social networking sites that are used by practically everyone. Medical information about diseases and conditions can be disseminated as well as directions to the nearest and most appropriate venue for care.
We know this is coming and can even predict the outcome if we are not adequately prepared. So lets head this advice and make this transition as smooth as possible.
More on this later.
Mark Brodeur
This is a terrible way to deliver this kind of care for a number of reasons. First and foremost it is extremely expensive. A typical ED visit costs about 5 times what a clinic visit would cost. Secondly the care in an ED is episodic. The ED physician has no established relationship to the patient and no history to work from. This often leads to overtreatment and rediagnosing established chronic conditions of the patient.
So as we prepare for the addition of many new patients who will have insurance coverage for the first time, it is important that we take steps ahead of time to ensure that that are treated in the appropriate setting. We can not sit back and expect that this will happen by itself. The Washington Post recently published an article written by a San Francisco ED physician, Dr. Jennifer Brokaw, who lists 4 steps that should be occurring now.
1) Establish more offices, clinics and urgent care centers, particularly in medically indigent areas.
2) Invest in more allied health professionals and physician extenders. It is clear that we will not have a sufficient number of primary care physicians. We need to be ready to delegate some of this works to others.
3) Start coordinating the various delivery systems that currently do not communicate with each other. We know a great surge in demand is coming. Providers need to work together to make sure the supply of providers and support modalities is adequate.
4) Take advantage of the internet and social networking sites that are used by practically everyone. Medical information about diseases and conditions can be disseminated as well as directions to the nearest and most appropriate venue for care.
We know this is coming and can even predict the outcome if we are not adequately prepared. So lets head this advice and make this transition as smooth as possible.
Mark Brodeur
Tuesday, May 18, 2010
More Bad News For The Cost Of Healthcare Reform
One of the key provisions of the new healthcare reform law is ensuring that people at high medical risk and those with pre-existing conditions will be able to obtain healthcare coverage. Often they are unable to get coverage in our current patchwork system. This is a very laudable and necessary component of the plan. But it appears that its cost to the system was not realistically estimated when putting together the cost figures for the new legislation.
The plan is to create high risk insurance pools in each state for all uninsured patients. $5 billion has been set aside to finance these plans. States are invited to set up their own plan and they would receive federal funding to operate them. If states opt not to develop their own plan, the federal government will set one up in that state. Thus far 18 states have decided against accepting the money and setting up a plan. Here's why.
It currently costs $2 billion annually to cover about 200,000 people under similar plans operating in 34 states. It is projected that the new high risk pools will be covering 2 million additional people between now and 2014. In addition, it is estimated that this pool of patients will be costlier than current pools. Therefor the real cost estimates are somewhere between $25 and $40 billion. The current $5 billion in funding is expected to run out by 2011. States are legitimately concerned that if they set these up, they will be left holding the bag when funding dries up.
Once again, I am not suggesting that we abandon this concept. Dealing with this important issue is necessary. And there certainly are significant costs already in the system to provide care for these patients. You can find these costs on the hospital's bad debt and charity write offs. But before we charge in with a grossly underfunded fix that will fall flat in a year, lets think this through. This is another example of the cost paid for rushing a bill through Congress without adequate input and discussion.
More on this later.
Mark Brodeur
The plan is to create high risk insurance pools in each state for all uninsured patients. $5 billion has been set aside to finance these plans. States are invited to set up their own plan and they would receive federal funding to operate them. If states opt not to develop their own plan, the federal government will set one up in that state. Thus far 18 states have decided against accepting the money and setting up a plan. Here's why.
It currently costs $2 billion annually to cover about 200,000 people under similar plans operating in 34 states. It is projected that the new high risk pools will be covering 2 million additional people between now and 2014. In addition, it is estimated that this pool of patients will be costlier than current pools. Therefor the real cost estimates are somewhere between $25 and $40 billion. The current $5 billion in funding is expected to run out by 2011. States are legitimately concerned that if they set these up, they will be left holding the bag when funding dries up.
Once again, I am not suggesting that we abandon this concept. Dealing with this important issue is necessary. And there certainly are significant costs already in the system to provide care for these patients. You can find these costs on the hospital's bad debt and charity write offs. But before we charge in with a grossly underfunded fix that will fall flat in a year, lets think this through. This is another example of the cost paid for rushing a bill through Congress without adequate input and discussion.
Mark Brodeur
Monday, May 17, 2010
Healthcare Reform Now Predicted To Be More Costly Than Originally Projected
Who didn't see this one coming? Now that we have healthcare reform passed and all of its provisions that were contained in the 2000 page document are being analyzed, it appears it will cost us a bit more than projected. The Congressional Budget Office (CBO) is now estimating that the new law may cost an additional $115 billion over the next 10 years. If Congress approves all of the additional spending called for in the legislation, it could push the 10 year cost of the overhaul above $1 trillion.
The additional expenses include $10-20 billion in administrative costs for agencies to carry out the law, $34 billion for community health centers and $39 billion for Indian care. These costs were not included in earlier estimates because they are not mandatory under the new law. They will need Congressional approval at a later time. My guess is that this approval will be difficult to obtain particularly after this November's elections.
Don't get me wrong, I believe that healthcare reform is not only a good thing but also necessary. Ignoring the uninsured and pretending that they currently do not cost the system anything is folly. I am glad to see coverage for these folks expanded. I am also pleased with the push for preventive and primary care coverage. But keep in mind that the real driver of healthcare reform is the fact that the current system can't continue to finance the cost increases we are seeing. We need to focus on how to make healthcare more cost effective. Some of the provisions in the new law address this while other obvious areas that do not fit the current political climate (ie: tort reform) are being ignored.
I don't see how the system will support an additional $115 billion over the next 10 years. Obviously not all of the provisions will be fully funded. But as cuts are made to make the new healthcare reform more affordable, let's not forget the real reason that we need it in the first place.
More on this later.
Mark Brodeur
The additional expenses include $10-20 billion in administrative costs for agencies to carry out the law, $34 billion for community health centers and $39 billion for Indian care. These costs were not included in earlier estimates because they are not mandatory under the new law. They will need Congressional approval at a later time. My guess is that this approval will be difficult to obtain particularly after this November's elections.
Don't get me wrong, I believe that healthcare reform is not only a good thing but also necessary. Ignoring the uninsured and pretending that they currently do not cost the system anything is folly. I am glad to see coverage for these folks expanded. I am also pleased with the push for preventive and primary care coverage. But keep in mind that the real driver of healthcare reform is the fact that the current system can't continue to finance the cost increases we are seeing. We need to focus on how to make healthcare more cost effective. Some of the provisions in the new law address this while other obvious areas that do not fit the current political climate (ie: tort reform) are being ignored.
I don't see how the system will support an additional $115 billion over the next 10 years. Obviously not all of the provisions will be fully funded. But as cuts are made to make the new healthcare reform more affordable, let's not forget the real reason that we need it in the first place.
Mark Brodeur
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