Idea #228 for October 4th, 2009: Closing Time or Nursing Homes Face Closures Amid Recession

Between shrinking state budgets and a new Medicare rate adjustment, many nursing homes in this country are nearing financial crisis. Twenty-four states so far this year have cut nursing home spending and a CMS adjustment will cut $16 billion from nursing home funding over the next decade.  Over the next ten years, President Obama aims to cut an additional $300+ billion from CMS, which may impact nursing home budgets further. With the retirement of the baby boomers looming, something will need to be done to prevent catastrophe.

Amid the financial woes, the rate of nursing home closures is rising while the number of patients in nursing home care also increases. Part of this year’s stimulus bill included $87 billion in funding for state Medicaid programs, however some states have diverted that money towards other, non-health related budget gaps. Last year, nursing homes got shorted over $4 billion in un-reimbursed costs under Medicaid. In the immediate term, we should at least disallow the practice of states misspending federal money earmarked for Medicaid funding. In the long term, we have to think about ways to dedicate more, rather than less, funding to nursing homes, which will see a steep increase in patients in coming years.

Read about this issue in the news here.

Idea #204 for September 10th, 2009: Hands-On Approach or Joint Commission Takes on Handwashing

The Joint Commission, which serves as an accreditation body for healthcare organizations, will soon be expanding its role in the health system. They will begin rolling out programs to identify and rectify problems in patient safety, in addition to the certifying they already do. The task will be carried out by a new division of the Joint Commission called the Center for Transforming Healthcare.

The first project to be tackled under the new initiative is the Hand Hygiene Project, which aims to increase hand-washing compliance among hospital staffs. Infections kill 100,000 patients a year in hospitals and may cost the nation billions of dollars, and better hand-washing is believed to be the best way to decrease those numbers. The pilot project in eight hospitals used undercover observers to note hand-washing compliance in those facilities. They found that less than half of staff were washing their hands before entering patients’ rooms.

After observing and compiling data on hand-washing, the next step was implementing changes to resolve the issue. At those eight hospitals in the pilot program, improvements were made and the hand-washing compliance jumped to 75% within a few months. Still, that number is below the target of 90%, but it is improvement nonetheless. The fact that the Joint commission is taking a more hands-on role in fixing healthcare is a positive development. If this hand-washing trial is any indication, outcomes could be drastically improved with some minor adjustments.

Read more about this program in the NY Times and Wall St Journal.

Idea #200 for September 6th, 2009: The Trust Factor or Restoring Faith In The Healthcare System

A survey conducted by researchers in Baltimore suggests that gaining patients’ trust is key to ensuring they maintain their wellness. People who have skeptical or negative views of the healthcare system are less likely to keep medical appointments, fill prescriptions, and continue medical care. It wasn’t just a mistrust of individual doctors that marred the peoples’ opinions, but a mistrust of multiple parts of the system including insurers and hospitals.

Making sure that patients have faith in the healthcare system is important for several reasons. For one, people will neglect or delay treatment for conditions that will likely worsen with time. That leaves patients sicker, and costs of treating them only increase down the road. Further, patients who inherently distrust the system are more likely to enter malpractice litigation, further driving up healthcare costs. So it’s important that doctors, insurers, and other players in healthcare make efforts to gain the trust of patients. It’s a factor that should be carefully considered in the course of the ongoing healthcare reform debate.

Read  more about the study in this US News article.

Idea #170 for August 7th, 2009: “Open Your Window and Say Ahhh” or Drive-Through Emergency Departments

We have drive-through restaurants, banks, and pharmacies, so why not drive-through emergency rooms? Stanford Hospital has begun tackling that question with test trials this year. In June, the hospital set up a simulated drive-through emergency department in a parking garage, complete with cars and fictional patients. The goal: to test if this method of seeing patients during a pandemic or bioterror attack would be feasible.

The impetus for the experiment was the overburdening of emergency rooms that commonly occurs during flu outbreaks, when people without insurance or primary care providers have no other recourse. During the test, the fake patients were assigned different symptoms and levels of sickness, so that the triage efforts of the staff could be tested. First, as cars entered the facility, patients were registered. Then the cars stopped at a station where patients’ vitals and medical history were taken. After that, doctors at the next station made a diagnosis and either admitted them to the hospital or routed them somewhere else.

The results of the experiment showed that patients experienced wait times 1.5 hours shorter than similar ones would have experienced in a traditional emergency room. Additionally, keeping patients in their cars isolates them so that illnesses are less likely to spread among potential patients. The trial went smoothly enough that the Stanford doctors are planning to roll this out in the event of an actual swine flu outbreak at this location. In an actual emergency, I wonder if dozens of panicked individuals in the drivers’ seats would result in some kind of traffic accident in the drive-through facility. Still, this is promising enough that it makes sense for other hospitals to implement, after doing some dry-runs of their own.

Read more about this in the Wall St Journal and in the Mercury News.

Idea #163 for July 31st, 2009: Sunlight Is The Best Disinfectant or Eli Lilly Discloses Registry of Doctor Payments

Earlier this year, under mounting pressure from the Obama administration, industries in the health field including drug companies promised to make some concessions to do their part in reforming healthcare. Eli Lilly announced this month they will publish a registry of doctors who served as paid consultants during the first quarter of this year. A total of $22 million went to those providers earlier this year, with the average consultant making about $1000.

Payments to doctors by drug makers, device makers, and other industry groups always create the perception of conflict of interest. In the past few years, Eli Lilly has disclosed some of its other financial dealings like grants to non-profits and academic institutions. Increased transparency is always welcomed. This may be just the start of more concessions made by those in the healthcare industry in the coming months. Patients should be able, in the near future, to search for providers’ dealings with industry when deciding who to seek for treatment.

Read more about this in the Wall St Journal, and see Eli Lilly’s registry here.

Idea #117 for June 15th, 2009: Missing the Point or Closing Loopholes in Healthcare Reform

With healthcare reform near the top of the new administration’s to-do list, some are looking at Massachusetts’s mandatory health insurance law as a model for national consideration. Whether their initiative has been successful or cost-effective is a topic for another day. But if a similar plan is considered nationwide, federal lawmakers should be aware of loopholes that exist in Massachusetts law that are giving employers too much wiggle room in their obligation to provide health insurance to workers.

Under that state’s law, businesses of 25 or more employees are required to offer insurance to employees, but exactly what constitutes an acceptable insurance plan is not well-defined. One murky requirement of the plans is prescription drug coverage; all plans must include the coverage, but whether plans could impose limits on those prescription drug benefits was not written included in the law. Thus, some companies have provided insurance that puts a cap on annual prescription coverage, which is contrary to the intent of the state’s healthcare reform effort.

Another shortcoming is maternity care for dependents of a plan’s subscriber, which a number of companies’ plans do not include. Again, without precise enough definitions in the law, employers are able to get around providing coverage in a way that the legislators originally intended. Even more problematic is the fact that employees, and not employers, are responsible for making sure their coverage is adequate in the eyes of the law. So if a company’s plan is deemed insufficient by the state, the employee will either have to purchase another plan or be hit with a $1,000 tax penalty. Overall, federal legislators should be aware of loopholes like these if they ever consider a similar law.

Read the story on the matter in the Boston Globe.

Idea #111 for June 9th, 2009: Packing For a Trip Nobody Wants or Elderly Patients Can Prepare for Hospitalizations

Be prepared: it’s the Boy Scout’s motto and it applies to patients too. Anything a patient can do to help doctors out will in turn lead to better outcomes for the patient. For elderly people or people with illnesses that could potentially require hospitalization at any time, there are steps that can be taken to ensure a smoother process. As mentioned in a Dallas Morning News article, preparing a collection of certain medical items can assist any paramedics or doctors who may see the patient.

Having medications collected, and things like contact information written down ahead of time can save some headaches for a patient who may end up in an emergency room. Also, having an advance directive handy helps ensure that correct end-of-life decisions will be made. And if patients really suspect they will be in and out of hospitals a lot, they can pre-pack some clothes and reading material that will be included with those other items. This is just another small thing patients can do to help the doctors who will be helping them.

See the news story on this in the Dallas Morning News.

Idea #108 for June 6th, 2009: Unintended Consequences or Who Pays for Patient Falls?

Patients falling down in hospitals is a dangerous and costly problem. About one in five patients will be injured in a fall, raising their bill by about $4,000 on average. Medicare refuses to pay for care stemming from what it considers preventable falls. But falls in general aren’t as preventable as one might think. Patients are sometimes disoriented or impaired to begin with, which is then compounded by medications given to them during their hospitalization.

An opinion piece in the New England Journal of Medicine argues that Medicare’s reluctance to pay for fall-related care will encourage hospitals to restrain more patients, which can have adverse outcomes. With hospitals on the hook for any fall-related care, they may use restraints as a preventable measure, but doing so is not in the best interest of the patients. They point to research showing that restraints can cause bed sores, breathing trouble, and cause general discomfort as reasons why hospitals should use them judiciously. Monitoring or other means would be preferable to restraints, but Medicare has not provided guidelines on preventing falls, so the concern is that hospitals may opt for restraints as an easy solution. Until guidelines are provided by Medicare for avoiding preventable falls, their insistence that falls be classified as no-pay events may only harm patients in the long run.

See the piece in NEJM and a news story about the issue.

Idea #100 for May 29th, 2009: What is EMR or The Heart of the Matter? Part 1

On this very special 100th post edition of Health365 I am tackling perhaps the heart of all contemporary healthcare issues. That issue is defining truly, madly, deeply, what, in fact, is an EMR… Today that is a question when I ask 1000 physicians I get 1000 different answers.

Recently I was speaking with a senior physician at a very prestigious American hospital with virtually unlimited funds, it’s a short list, I am not going to name names. Despite having an EMR system and “digital workflow” and having spent nine figures on getting there, the doctors at this facility are today, in fact, doing their progress notes on… paper. After the fact data gets entered back into the electronic system, hopefully sooner rather than later.  The doctors for a variety of reasons can’t make the digital progress note work in real time and reverting to paper is workable for the time being. While they may claim to be using EMR, I think it’s hard to call  what they have truly an EMR. This reminds me of the story told in “The Data Model That Almost Killed Me” . Delayed entry in many cases, particularly in a hospital environment with the expectation of a “digital workflow”, can be worse than the paper process that existed before the “EMR” implementation. It is going backwards not forwards.

So what does make an EMR, I think there is really a pretty simple forumla that works in all the cases I am familiar with. There are three parts to an EMR: technology + reasonable cost = improved patient outcomes. Something that fails to meet the laugh test on any of those three components cannot be considered an EMR. An EMR that improves patient outcomes but comes at an exorbitant price is not an EMR. Same goes for one that is cost-effective, yet has no positive effect on patient outcomes. Taking a look the major hospital I eluded to above they spent well beyond what any sane person would consider reasonable, they are now not even really using the technology they paid for and they have yet to measure any substantive improvements in patient outcomes, while the system is technically working I would call it a failure as an EMR.

Pinning down the precise meaning of “improved patient outcomes” can be a difficult task and is outside the scope of this first post, but I’ll touch on it in a forthcoming entry. There is a lot of confusion about the differences between EMR, EHR, PHR, etc., but arguing over those kinds of semantics is a waste of time, frankly. The main point is the equation I just mentioned, if you don’t have those three components, the rest is immaterial. As the feds wrap up their testimony (including my contributions) on meaninful use more and more I hear amongst those in the know that this 20 billion dollar incentive package is going to result in more of the same, that is more nine figure “EMR” installations where the key data points still make their way to paper first. There is hope though, there is a shining example of how EMR can be done not perfectly but very well on a very large scale and of all institutions it is facilities run by the VA that make the grade. Congress knows this but have not yet learned the lessons of why the VA has been successful and instead focused on superficial elements. The remainder of the posts in this series will delve deeper into the issue of EMR, what is it and how to do it, so stay tuned…

Idea #81 for May 10th, 2009: Cutting The Red Tape or Encouraging Employee Wellness Programs

Employers have figured out that a healthful workforce is a more productive and less costly (in terms of insurance premiums) workforce. That’s why some companies offer employees incentives for adopting healthier lifestyles. It’s a win-win situation. Now Congress is considering changing laws to make those kinds of wellness programs easier for companies to implement.

Encouraging healthy living among workers can really put a dent in the massive amounts of money our nation spends on healthcare. Chronic conditions like diabetes, high blood pressure, and obesity account for a tremendous amount of health spending, yet they are mostly preventable. Additionally, employee smoking cessation programs can help thwart the many illnesses associated with cigarette smoking. Lawmakers have recognized the benefits of employee wellness programs and are now taking action.

One possible Congressional proposal focuses on giving tax credits to employers that use health screenings and wellness counseling. There are also plans to cut the red tape that’s making it unnecessarily burdensome for companies to adopt wellness programs. Things like complex tax rules and insurance laws are getting in the way of companies implementing ideal programs. Anything Congress can do to make these types of programs more prevalent can really help our health — and our health spending.

See the story in the New York Times.