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Wednesday, December 28, 2011

Stopping the Over Charging in the U.S. Health Care System

How Profit-taking Distorts Health Care Delivery in America
Recently, a Public Broadcasting Station (Channel 9) featured a story on a for-profit hospital group which was using obscure diagnostic codes to achieve higher Medicare payments. The level of unethical and fraudulent activity was so egregious that more than one of their billing coders quit their jobs and testified against their former employer. The Wall Street Journal has also reported on fraudulent Medicare billing, including requisitioning public records from CMS(Medicare) and identifying abusive billing practices by multiple clinicians. For example, the New York City osteopath who billed Medicare 2 million for family medicine, when this was not the nature of her medical practice. WSJ staffers examined the Medicare database and uncovered 25 billing codes for an array of expensive medical tests which were regularly performed by 20 other clinicians in the country. Of that group, 33% have already been convicted of fraud, have undergone professional ethics investigations, or worked in the same firm as the convicted physicians. It is safe to say that this high correlation of billing blips is no accident. Unfortunately, because the American Medical Association prohibits the government from disclosing clinician compensation, even if billing practices are fraudulent, those physicians are not publicly named. Basically, this means a lot of people are still getting away with fraud. This article reviews how profit-taking motives distort the U.S. health care system and does not contribute to health care improvement.

First of all, it is legal to deliver health care services and make a profit in the United States, but it is not legal to defraud the government or private sector insurance companies by making false claims to incur higher reimbursements. In plain language, this is known as stealing and this article will show how the incentives to steal are so high in the current U.S. health care system that despite penalties, including jail sentences, the phenomena continues to rob money from all U.S. health care payers. The payers are the individuals who must obtain health care services at inflated prices to subsidize excessive profiteering and fraudulent activities in many sectors of the national health care milieu.

By focusing on changing the alignment of reimbursements for many health care providers from a volume-based principle to outcome-linked measures we will be able to identify the outliers in the shell game of medical monopoly. Several aspects of the 2010 health care reforms seek to address the abuses of health care reimbursement in the country, including more stringent requirements for health insurance company financial reporting of premium payment utilization. Additionally, there are financial incentives for clinicians who achieve better outcomes for targeted medical conditions under the Shared Savings Rules. And finally, the systemic review of medical supplier over-charging is also included in the reform provisions.

Accountable Care & Incentives for Health Care Outcomes
Accountable Care rules for hospitals and integrated health care organizations include Shared Savings methodology or a bonus if you will, for those medical groups which produce desirable clinical outcomes. This realignment in Medicare & Medicaid reimbursements will ultimately save U.S. taxpayers money for federally funded health care programs. In other words this changes the equation from paying for volume to actually paying for clinical performance, and the best performers will receive more money than those who have poorer clinical quality. For example, if your facility has more hospital re-admissions for a specific procedure than the evidence shows is desirable, that will impact your reimbursement. This is a good thing for the country, although I am sure some health care providers are concerned about the ramifications for their practices. Clinics and hospitals are not required to become designated as Accountable Care Organizations at this time, but the pay-for-performance methodology will ultimately be spread throughout the country as organizations respond to this trend.

Creating Efficiencies System-wide
As previously reported in 2010, the establishment of the Comparative Research Institute seeks to review system-wide data on medical equipment suppliers and clinician practices, in order to optimize value for U.S. taxpayers who fund federal health care programs like Medicare. Though this has been criticized as just another government agency, the purpose is to look across the health care system of disparate providers including; medical equipment suppliers, purveyors of high-tech devices, and clinics to find ways to save money for the entire system. Certainly not everyone will be happy with this process, but one wonders how many of them are in fact the excessive profiteers.

Like it or not, several components of the 2010 landmark health care legislation are here to stay because they profoundly impact Medicare and Medicaid programs, which consumes 32% of the 2011 federal budget. We do need to spend taxpayer money more wisely and part of that process includes scrutinizing all of the components of health care delivery. The government oversight is necessary to curtail cheating and other criminal activities.

A Clinical Case: How America’s Private Health Care System Is Not Producing Best Practice Results for Kidney Dialysis

A basic tenant of a capitalist economic system creates a disproportionate incentive towards money making activities which often fall short of optimal patient care. A good example of this capitalist infusion is the kidney dialysis system in the United States, which sprang up because of the congressional ruling to cover end-stage-renal-disease under the Medicare umbrella in the 1960’s. The entities that seized this “new market” were largely for-profit corporations. For those of you who do not know, kidney dialysis is a mechanical cleansing process which is lifesaving for those whose kidneys have ceased to support their renal systems. International data on dialysis treatment shows that Americans on dialysis do not survive as long as patients in other industrialized countries and also experience more clinical complications. This should come as no surprise when the corresponding American health care incentives are based only on providing the dialysis procedure, not optimizing patient health.
For the profitable dialysis centers, like DaVita, business has been brisk as the American population undergoing dialysis has grown from 11,000 people at inception to over 300,000 people today. Each patient on dialysis brings in about $72,000 just for that procedure, so the industry is worth billions. Examples of how the maximization of profit has impaired clinical processes include the dialysis center protocols which discourage the use of fresh kidney processing devices for each patient and thereby greatly increase the chance of infection. So some MBA figured out they could save their organization money by reusing artificial kidneys on a critically ill population and this has become a standard of practice.
Another example of a U.S. renal failure outcome which differs from other global practices is the limited number of dialysis patients who use the peritoneal process, which can improve the individual’s the quality of life. Clinicians have suggested that American patients are often too ill to be eligible for the home-based peritoneal process. As a society which is paying for this treatment, we need to be asking what we can do to treat these people earlier in their disease progress, so they may become eligible for less taxing treatments(and less expensive). Too often the U.S. health care system steps in literally at the “end-stage-of-treatment” because our system of economic reinforcements only assures payment at that time. This dichotomy is what needs to change.

Evidence-based planning which I have previously written about (and continues to be one of the most popular articles for this readership) is all about reviewing appropriate scientific data to discern the optimal blend of clinical intervention and patient outcomes to benefit a population. This process is what we need to be doing as a nation in order to optimize health care services for the entire population.

Election Implications
Since 2012 is an election year, when you start to hear the rhetoric of “getting the government off our backs” remember that doesn’t mean you will pay less for your health care premiums or services. In our blended system of public and private health care services, we must have an external audit and enforcement arm and the government does this for us all. Like it or not, our government does perform essential services which benefit the average American. The 2012 election mantra should be focused on creating government oversight linked to performance outcomes, not merely less government.

Basic Economics
Anyone who has taken basic economics coursework knows that government intervention occurs when there is a failure-to-perform in the private sector. Certainly, the executives at Premera Blue Cross understand this principle, which also explains that entity’s rush to embraces some changes in their health insurance model. The old insurance company model was a paternalistic one where insurers dictated what they would cover, but the new model requires further explanation and reporting of clinical results, because of government requirements. Reporting results is a good thing for the health care consumer and the edict to explain them in an understandable transparent manner is a victory for health care consumers. This transparency also includes the disclosure of the commissions your insurance agent makes and there is nothing to be ashamed of there, if your agent or broker is working on your behalf and is not over charging (group insurance commissions are negotiated for experience-rated groups). In the truest sense of an open market, price information is available to the consumer who is then empowered to choose an agent or service provider for both the price and the value. Hopefully the disclosure will extend to voluntary health and accident programs as well, as some of the greatest abuses of value occur in that area.

The healthpolicymaven will be speaking at the Northwest Women’s Show March 2nd, 3rd, and 4th on the U.S. Health Care System and How to Optimize Your Health Care Outcomes in the Face of Reforms.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

Sunday, December 4, 2011

Why Diabetes Prevention and Management and the U.S. Health Care System Are At Odds

Diabetes Current-State and Changes to Come

Unless you are Cro-Magnon-man and just emerged from a glacial field you are probably aware of some of the 2010 health care reforms. This article reviews how the United States got to be in such poor shape, health-wise and how some provisions of the 2010 reforms will create incremental changes.
Since I am nearly finished with my second book, the Russell Guide for Diabetes: Type I or Type II This Could Happen To You, let me share some mind boggling information about this scourge. The American statistics on this disease have a huge impact on government funded health plans, including Medicare and these metrics from the CDC explain why :
• The proportion of diagnosed diabetics in the United States has increased by more than 50% since 2007; 17.7 million in 2007 and 25.5 million in 2010
• Fully one third of the U.S. population is expected to be diabetic by 2025; 115 million
• In 2010 18.7% of the 25,564,000 U.S. residents diagnosed as diabetic were African Americans and 10.2% of that number were non Hispanic ( White)
• More than 90% of all diabetics are Type II, which is controllable by diet and exercise
• The CDC estimates that 33% of the country is in pre-diabetic mode in 2011

Type II Diabetes is caused from obesity and a diet high in simple sugars and carbohydrates (think fast food, doughnuts, etc,) Being over-weight significantly increases your chances of becoming diabetic. I think it is time we Americans call a-spade-a-spade, so if one of these criteria fit you are fat:
1. 20 lbs. over weight-Yes, you are fat
2. 50 lbs. overweight-This qualifies you as obese
3. 100 or more lbs. overweight-Then you are exogenously obese
4. Body Mass Index or BMI exceeds 30 you are fat
5. If you have to replace the shocks on the driver’s side of your car more frequently than the passenger side, this is a clue that your girth has impacted vehicular performance.
6. If you have broken chairs in your house or someone else’s by sitting in them, yes my friend you are fat.
7. If you need to buy your clothes at Tacoma Tent and Awning, need I say more?
It is time we as Americans put down the doughnuts and look in the mirror. The country needs to go on a 12-Step Program for Over Eaters Anonymous. No more excuses, just bust a hump and get out there. Like everyone else I have had to battle-the-bulge as I’ve aged, but so far I do not qualify in any of the categories above.

Food is fuel and it really does matter what you consume. If you are going to persist in a diet that is high in simple sugars, lacking in fiber, and complex carbohydrates, it is similar to starving your body of essential food, so it craves more food. Diets which are high in “the whites” meaning white rice, white pasta, white bread, and sugar cause spiking in glycogen which is what the body creates when it breaks down food. Foods that convert to simple sugars cause the glycogen rush and over time damage the pancreas which ultimately ceases to work properly. At that point, listlessness, fatigue, and a sudden weight loss may be symptoms of diabetes. The United States has at least 5 million more people who are undiagnosed diabetics. The later diabetes is diagnosed the worse the damage is to the body systems. Here are some tips on wise food choices:
1. The large pizza is not intended for one person
2. 32 ounces of a soda-you may as well drink three beers calorically speaking; put down that big gulp unless you want the catheter that goes with it when you are on kidney dialysis later

What Happens If America Doesn’t Slim Down
Diabetes was the 7th leading cause of death in the United States as reported by the CDC for 2006 and it is advancing all of the time. And death from diabetes is not a quick process, but a torturous route of injections, circulatory problems (including amputations), hyper tension, and kidney failure. In the United States, 40% of diabetics end up on kidney dialysis. These metrics contrast sharply with other industrialized countries that have much lower renal failure rates, such as Austria at 30% or 34% in Germany. Life expectancy for someone on kidney dialysis in the United States is only a few years.

The link between heart failure and kidney dialysis is pronounced and a 2011 study showed that 36.1% of dialysis patient had high blood pressure, 38.2% had a history of heart infection, and 25% had excessive weight gain between dialysis sessions. All of these symptoms are exacerbated by the dialysis treatment process in the United States, which pushes patients to conform to business practice hours and not optimal clinical outcomes.

What are the Costs
The U.S. Medicare program has financed the cost for kidney dialysis for all persons who have Social Security numbers and are legal residents since 1973. President Nixon signed the legislation and at that time renal dialysis cost $12,273 per patient and 11,000 people needed it in the country. Fast forward to current time and dialysis now costs $77,000 per patient and there are over 350,000 people on it. The vast majority of people on dialysis are diabetic, with age being correlated with an increased incidence of renal failure. In 2010, Medicare spent 20 billion dollars on the renal dialysis program.

What Can Be Done
The vast majority of renal dialysis centers in the United States are operated by for-profit companies, like DaVita, fueled by Medicare’s reimbursement policy which rewards the process not clinical outcomes for dialysis centers. This may all be changing with President Obama’s endorsement of the Comparative Effectiveness Research Institute in 2010. This institute will look at clinical processes and outcomes across systems and compare them to global data to find ways for improvements. For example, the mortality or death rate for patients on kidney dialysis is much worse in the U.S.A. than in other industrialized countries, so this needs to be reviewed. And of course, a much greater percentage of American diabetics end up on dialysis than in other countries.

Another aspect of the 2010 Health care reforms was to require insurance companies to offer wellness or preventive care benefits. In my former career in the insurance business there was always a lot of teeth gnashing over offering preventive benefits because the industry promoted the idea the employees should pay for this service themselves. The industry also discouraged low co-payments or cost sharing as a means to lower the insurance premiums for the employer group. The problem with this mentality is it is inherently short term and the health of a person is a long term process. This is just one example of how the insurance industry has been at odds with promoting health for our country. Though it should be obvious, let me state that by mandating a base level national health surveillance system, such as an annual physical, offered gratis, we can find the people that are hypertensive or pre-diabetic and prevent more serious health damage. By reaching out and treating people earlier we will save money in government funded health programs. In order to accomplish this goal as a nation the country needs to continue to look at aligning provider incentives and reimbursements to promote national health not just a medical service. The goal of the country should be to work towards optimizing the health of its citizens not just treating their illnesses and injuries . If private sector insurance is to be a part of that equation, disease prevention services that are measureable and effective need to be included. Perhaps another model could include national clinics where physicals are administered by public health officials, which would provide privacy for the employee who may not wish to share his personal health metrics with the employer. Despite all of the HIPAA privacy hype, I can assure you there are a myriad of ways for an employer to discover employee health data, especially for a group which is self-insured.

On that note the healthpolicymaven is going to sign off and log my eight miles, which I have averaged per day this year. I recommend that you also slam down that pizza and put on your shoes.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

Monday, October 31, 2011

Rolling Back The Clock On Women's Health Care

Impact of the Vatican's Universal Translation of Faith, Catholic Owned Health Care Facilities and State Legislation on Health Care for Women
The triad of the new stricter Vatican rules for interpretation of Catholic protocols, the trend toward Catholic organizations purchasing non-Catholic hospitals, and the furor over the proposed women's health standards for the 2014 health insurance exchanges have made this a topic which must be revisited. In order of appearance here are the players:the Vatican, Swedish Health Services, and the State of Mississippi.

Vatican Rules on a Universal Translation for Catholics
Beginning November 27, 2011, the Vatican has issued another edict which attempts to tighten the interpretation of the Catholic faith, by mandating a single universal translation of the faith. The church hopes to reign in the more liberal interpretation which is prevalent in the United States and other western countries. Though one might think this only affects Catholics, not-so-fast, it affects all Catholic Church owned enterprises, including hospitals and schools, which serve an interfaith community and that brings us to our next player.

Swedish Health Services Acquiescence to the Catholic Entity Providence Health
Counter-intuitive to the trend of Catholic hospitals purchasing non-Catholic facilities throughout the United States, the secular hospital group, Swedish Health Services has acquired Providence Health Services hospital and clinics. However, what is most interesting about this transaction is the Pope still got his way, as the deal is subject to his approval, and he has mandated a line-item-veto on the secular facility’s ability to provide abortions. One could understand a Catholic hospital which did not wish to provide abortions, but Swedish is a secular institution and it is acquiring Providence. Though Swedish has indicated this wouldn’t have a huge impact on the service for women in the Puget Sound area of Washington State, they did not have any public hearings about this reduction in service. Clinically, there are cases where women may require a hospital facility for an abortion, but that doesn’t seem to matter here. At least in the Seattle area there are other secular facilities which will provide the service. It is important to note that the Vatican has specifically addressed the elective abortions, which can include victims of rape or incest. I am sure these women consider their legal health concerns to be paramount and hardly “elective.” Apparently there is no due process required if it concerns female reproductive rights, even in the highly secular community of Seattle, where Swedish is based. The fact that we have allowed our health care practice to be determined by a celibate male from another country offends not only me, but also the majority of residents.

According to a 2005 report by Catholics for a Free Choice , there are 60 Catholic health care systems located in all 50 states in the United States. One of the concerns about Catholic hospitals is do they restrict health services? This question applies not only for reproductive rights, but also for advanced medical directives for patients who wish to die without certain medical interventions. According to a 2006 survey by Pew Research Council, 70% of Americans felt that patients should sometimes be allowed to die, 70% also indicated they would rather die at home, than in a prolonged artificially extended manner in the hospital. Only 22% of those polled said that life should be prolonged using extraordinary measures. The majority of Americans shun the loss of dignity while being kept alive mechanically, but would a Catholic hospital respect their wishes? The nonprofit group Catholics for a Free Choice, states that Catholic hospitals do restrict health care services based on the edicts of the Vatican via the Ethical and Religious Directives for Catholic Health Care. It should be obvious that non Catholic patients as well as Catholics may disagree with these practices, so it behooves the patient to verify any service restrictions in policy and in practice in advance of treatment in a Catholic facility. Unfortunately, for many people in America this is not an option, as the only hospital in their area may be a Catholic institution, which has an impact on end-stage-of-life-care and other health services decisions.

Mississippi is Close to Defining Life as at the Point of Conception

Previously I have written about my 50-state analysis of the 2010 health care mandates for the regional insurance purchasing cooperatives, including the incendiary furor over women’s reproductive autonomy. Not to be outdone in its leap to the dark ages, the State of Mississippi is close to passing a law which defines human life as beginning at the moment of conception. Needless to say, this will be a sticky wicket when it comes to actually, catching-someone-in-the-act. The personhood law, if it passes will make it a crime for a woman to obtain an abortion at all, as the life of the fetus will supersede that of the woman who is already alive and kicking. Additionally, this “chastity belt” would also outlaw the use of certain birth control devices, including IUD’s which are intrauterine devices that allow fertilization but prevent embryo attachment to the uterine wall. Of course, the morning after pill would not be allowed either. Going a step further than just the birth canal, the destruction of any in vitro fertilized eggs would also be a crime.
The proposed law certainly cuts a wide swath across those who are fertile and those who may have fertility challenges. This state could potentially institutionalize pregnant women to enforce delivery and likewise for rape victims or incest victims. More to the point, for those fertile lasses who have already had several children while using various birth control measures, and decide they cannot afford more children, they would become criminals. It will be interesting to see how this one winds its way through the courts, if it passes the legislature.
Lest you want to write off Mississippi as an rogue state, Colorado attempted to pass similar legislation in 2008, which thankfully failed. In fact, Personhood USA is based in Colorado and is the backer for the Mississippi bill. Additional states who are considering personhood laws to circumvent the 1973 Roe versus Wade ruling that confirmed constitutionality for a woman to have an abortion prior to the fetus’s ability to live outside the womb include; Arkansas, Montana, Nevada, and Oklahoma.
From this vantage point there is no end-in-sight for the pitch back to the dark ages for women in the United States. I can almost see the black hole from here.
On a more personal note, I expect my book, Unraveling U.S. Health Care to be available within the first quarter of 2012 and yes, it is OK to say FINALLY. Anyway, thanks for reading and I hope you continue to review and comment on my musings.

Monday, September 19, 2011

Reducing Health Care Costs By Improving Primary Health Care

How Primary Care Reduces Health Care Costs in the Long Run
Now that the teeth gnashing over health care reforms has been ongoing for two years, before the lifelines are cut on financing health care for the forty-nine million uninsured population, let’s examine the health care continuum for the impact of a failure-to-fund the health insurance subsidies. One of the things that is missing from many discussions and assertions about the 2010 U.S. health care reforms are which systems need to be changed in order to reduce the long term cost of American health care. And when I say reduce, I mean reduce the cost increases in providing health care to an aging population. It is essential the U.S.A. get the per-capita cost of its health care in-line with other nations, as it gobbles funds that could be used for education, capital investments for industry, and other economy building activities. The country will need to make substantial investments in k-12 education as well as building a more energy efficient infrastructure to have a chance at competing with global leaders for competitive contracts, as Germany and other countries have done. This article addresses the components of American health care that are impacted by the 2010 mandates and what it means for managing patient care over a lifetime.
Rather than thinking of health care as a commodity that deserving people get, for those who have worked where it is provided by an employer or who qualify for Medicare by virtue of accumulating enough quarters of eligible earnings, or military personnel, please consider it a part of the national infrastructure for a moment. A healthy population is necessary to obtain optimal output from workers, students, and for the care of our families. The provision of health care may be considered a utility. Utilities are measured by their output, the efficiency of their output, and the cost of producing the service. Measuring quality across the United States health care system, which is disparate and complex, is a major challenge in building higher efficiency into American health care.
Measuring Health
From the moment we are born until we die, we are introduced to various aspects of health care in the U.S. system. Even from birth, we do not provide the same level of care to all pregnant women, nor do all babies have the same chance of surviving their first year in America. In my book, Unraveling U.S. Health Care, I researched all fifty states for health metrics, including infant mortality statistics and in one area of the country, infant mortality was as poor as it is in developing countries (12.6 deaths per 100,000 babies for the District of Columbia) Only in a hand full of states was the infant mortality rate equal to European standards, of 5 or fewer deaths per 100,000 infants. Health care workers do understand and are alarmed about this dramatic difference in a basic health care outcome in the country; however, it seems much of the population is uninformed. A basic measurement for health is infant care and reducing the chance of infant death.

Another health care measure is degree of healthy living, as measured by the DALE or Disability Adjusted Life Expectancy, which measures the number of years an American can expect to live healthily, able to move around, and do their activities of daily living. In other words, how many years you can expect to be reasonably free of impairment from chronic disease. The World Health Organization, developer of this index ranked Japan as the number one country for living longest in good health to an average age of 74.5 in the year 2,000. Though the earthquake and tsunami disaster may have some impact on this in the future, the Japanese have a national health care system designed to provide primary care for their population. The United States ranked below all other developed nations in these criteria, with a Dale index of 70 years. Women are expected to be healthy to age 72.6 (true in my Mom’s case), and American men are only healthy to age 67.5. Wake-up call for boomers born in 1957 or later, you are not eligible for full Social Security benefits (under current standards) until age 67, so guys, just about the time you are expected to lose your quality of life.
The ability to live free of chronic disease is an indication of the effectiveness of a health care system and how it identifies population needs and deploys successful interventions. The U.S. health care system has been less focused on primary care, largely because clinician reimbursements and the high cost of medical school have driven more practitioners into specialty care, which treats disease, but is not geared for prevention of chronic disease. One of the provisions of the 2010 health care reforms is the Medical Home provision in Medicare, which attempts to correct the primary care problem by paying clinicians more to be the primary care provider. This concept is a start in the right direction, but as a nation we need to have more health care incentives for primary care, which prevents chronic diseases from birth through life expectancy. Only through this process can we hope to reduce the incidence and associated costs, both social and economic of chronic disease like Type II Diabetes, hyper tension, and heart disease.
Cost of Delaying Treatment
As cited above, the United States had the poorest score for healthy life expectancy of any industrialized country, literally at the bottom, yet we spend 25% more than any other country in the world. The only way we are going to be able to change this result is to build efficiency into health care delivery and improve basic preventive and primary care.
Arguments about a person’s right to health care miss the Titanic-size glacier that pummels U.S. hospital systems, which is EMTALA, the Emergency Medical Treatment Act which requires all hospitals to treat patients, regardless of their ability to pay for services. States with huge uninsured populations, like Texas, with over 25% lacking any insurance , and half of those people are working for employers who do not provide any medical insurance . Not only do those people lack access to primary care, they appear at the hospital emergency department in advanced stages of chronic disease, which must be treated. This is not an effective way to deliver health care as a nation. Hospitals are designed to treat the acutely ill, not to provide primary care. Much discussion has occurred around the health care safety net for the nation, which directly addresses the ability of these hospital systems to continue to provide free care and pass those un-reimbursed charges on to full paying customers, enrolled in private sector health care plans.
Pass-Through Costs in the Health Care System
To those who complain about providing health insurance for the uninsured, a significant portion of the insurance premium these individuals already pay is based on reimbursing hospitals for under payment serving the uninsured and to a lesser extent, Medicare and Medicaid patients. By deferring treatment in the form of primary care, the nation has elected to force these folks to develop worse chronic disease conditions, which are more expensive to treat, and result in premature death from preventable conditions. In health care, treating a patient earlier in the care continuum is best clinically and economically and this is the direction the nation needs to go. For all of the caterwauling about health insurance rate increases, if there is any hope of stabilizing these impacts, it must be driven by increasing patient access to early and consistent primary care. Further, to those who object to paying a portion of their taxes for the provisions of health care, you are already doing so, by paying more than any other country for your health insurance and the administration of your health care. A better question would be how can we reduce the cost of health care overall? Should be continue to have employers contributing to health care financing or go the European route of having the individual be responsible? And finally, health insurance is a financing tool and not a delivery system for health care. We need to improve how we provide basic health care, including disease surveillance, continuity of care for those with chronic disease, and assurance of quality care throughout the country, not just for the lucky few who live close to centers of excellence.
Moving Forward
The 2010 health care mandates attempt to address these concerns in a number of ways, including improving access to primary care by subsidizing health insurance purchasing for small businesses and individuals and thus increasing the number of people who have health insurance and thereby the ability to obtain care. The Medical Home provisions are a start to addressing the access problem that seniors have with Medicare, which pays so little to doctors providing the care. And the Accountable Care Organization standards will pay health care systems more money for high quality patient outcomes in targeted areas for Medicare. FYI, changes in Medicare become a part of the private sector as well, so health care reporting of patient outcomes for Medicare, will also be reflected in the rest of the nonmilitary (Veterans Administration has its own health care system)population. None of these components of the 2010 reforms will go away, but further wrangling will continue on standardization of care for the health insurance purchasing cooperatives and the insurance purchasing subsidies. In a worst case scenario congress may choose not to fund the subsidies to help people buy medical insurance, which would of course result in tax penalties on all of the private sector who decide they cannot afford to buy the insurance. But then again the United States is famous for its unfair tax policies which tax the poor and middle-class much more than the wealthy. Just remember any deferment of health care access and treatment now will result in more serious chronic diseases later, which we will pay for, by increased hospital charges apportioned across the private sector insurance payers and higher costs for government health care programs.

This article was written by Roberta E. Winter, MHA, MPA an independent health care consultant and journalist and may be reprinted with her permission.

Saturday, August 6, 2011

Improving Health Care at Hospitals

Methods for Improving Health Care in the Hospital
The Centers for Medicare and Medicaid have required hospitals to start reporting on quality criteria for reimbursement consideration as early as 2012, based on 2010 health care reforms. Major changes that clinicians and hospitals must conform to include:
Value-based Purchasing-This provides greater reimbursement with an emphasis on better clinical outcomes, starting in 2013.
Risk-Adjusted Reimbursement-This accounts for higher risk patients with multiple conditions and gives the doctor a higher fee to manage their care than previously, effective in 2014.
Reduced Payments for Hospitals with Excessive Re-admission Rates-This is a penalty for poorer performance and is effective in 2013 for hospitals who do not perform within certain guidelines for specific diagnoses.
This article reviews a report commissioned by The Commonwealth Fund to analyze some of the things the top performing hospitals, who submitted to quality surveys by the independent quality watch dog nonprofit, Leapfrog Group, are doing to improve clinical care and efficiency at their facilities.
Case Study Criteria
This information was drawn from case study analysis of 4 hospitals out of the top 13 hospitals in Leapfrog's Highest Value Hospital criteria using their 2008 survey data. Standards reviewed included short lengths of stay and low readmission rates for the following cardiac procedures; CABG, PCI, and AMI, in addition to pneunomia. The case study review was conducted by Jennifer Edwards, Sharon Silow-Carroll, and Aimee Lashbrook in a report entitled, Achieving Efficiency: Lessons from Four Top Performing Hospitals and was published as a Synthesis Report for the Commonwealth Fund in July 2011.Hospitals included in the report are Fairview Southdale Hospital in Edina, Minnesota,Park-Nicollet Methodist Hospital in Minneapolis, Minnesota, North Mississippi Medical center in Tupelo, Mississippi, and Providence St. Vincent's Medical center in Portland, Oregon. These hospitals scored high in at least three of the four criteria and were recognized as high value hospitals. The Commonwealth Fund commissioned the study in order to assess what hospitals were doing to create high quality outcomes with low resource investments, in other words, producing good results for less money. Here are the top factors influencing high patient quality outcomes at hospitals, listed in order of precedence:
Full-time Quality Assessment Departments
All four hospitals have full-time quality development, measurement, and compliance departments, but the difference between the best scoring facilities and the medium hospitals was how they trained their staff to solve quality problems as a part of their job. This includes clinical and nonclinical staff that assess performance improvement processes. At Fairview Southdale, every department director is required to sponsor at least two initiatives to improve clinical quality and produce a minimum of $60,000 in savings yearly.
Matrix Management Models Enhance Fluid Organizational Changes
In the top hospitals, executives with more fluid organizational roles rather than hierarchical, were able to make systemic adjustments more readily. Matrix operational models support management changes based on organizational links impacting outcomes rather than chain-of-command methods.
Increased Use of Hospitalists as Patient Care Coordinators
All four of these hospitals used hospitalists to coordinate inpatient care rather than "on-call" physicians. These full-time clinicians make patient assessments and provide greater continuity of patient care, making it easier to measure and track patient health. It is easier to implement standards of practice changes with full-time employees than independent contractors. Notably, the Accountable Care Organization criteria looks at reduced hospital re-admissions when rewarding hospitals with higher payments.
Engaging Staff: Quality Improvement is the Responsibility of Everyone
North Mississippi Medical Center, a recipient of the Malcolm Baldridge Award for Quality, solicits all its employees for ideas on process improvement and in 2008, 37% of those were implemented. This process is reinforced through recognition and incentives. Staff empowerment is also one of the measures for the Baldridge Award. St, Vincent's Hospital in Portland, Oregon created a new model to increase staff engagement, called self-governance or one-team-many-hands approach, which gives all staffers representation in hospital decision making.
Information Systems Supporting Patient Care
St. Vincent's and Fairview Southdale are part of integrated systems where patients can request medications on-line, facilitate non emergency health assessments, and schedule appointments. It is much harder for nonintegrated health systems to offer these tools, but here are some of the creative things these facilities have done with technology to improve patient care:
1. An electronic bed board for optimizing facility space and accommodating patients.
2. Patient discharge systems for streamlining patient processes when leaving the facility.
3. An internal alert process when a unit is close to capacity so other departments can handle the back fill.
4. Fairview Southdale uses wireless technology to allow ambulances to send electrocardiograms to the hospital when a patient is enroute, which reduces patient care time by twenty minutes.
Standardization and Simplification
All four hospitals had processes to eliminate unnecessary redundancies, reduce patient slow downs, and stop errors. Something as simple as a defined protocol for assigning a bed for a patient eliminated slowdowns. And in health care, minimizing delays means patients obtain care quicker and financially the facility is able to optimize its resources for all patients. St. Vincent's uses a staggered staffing system to avoid shift change down time.
Centers for Medicare and Medicaid Demonstration Projects
Here is a brief list of health care demonstration projects through CMS:
Global Capitation Payments-This is a project which is in five states and attempts to address the hospital safety net, which is the extent hospitals serve the poor and uninsured, and it runs from 2010 to 2012.
Medicare Shared Savings-This is part of the Accountable Care initiative, which rewards clinicians for performing within certain evidence-based standards for targeted diagnoses beginning in 2013.
Medicaid Children's Health Insurance Shared Savings Program-Like the adult shared savings program.
Bundled Medicaid Demonstration Projects-This reviews episodes of care in a hospital and other settings, is deployed in eight states, and runs from 2012 to 2016.
Bundled Medicare Payments-This is a method of enhancing primary or Medical Home provisions to increase clinician reimbursement for patient care.
In closing, all of the selected hospitals were part of health systems, where benchmarking and resourcing services are readily available, which could be problematic for community hospitals lacking these resources. Still, these four stellar hospitals provide creative solutions for managing patient care on a budget, in urban and suburban settings.
It was excruciating to sequester myself to write this article when it is the peak of the Pacific Northwest nirvana weather, so I thank those of you who are going to read it tomorrow morning when it posts. My service to you is reducing the 25 page report down to less than 2 pages. This is the healthpolicymaven signing off in 78 degree air with 56% humidity.

Saturday, July 2, 2011

Consumer Tips for Surgery

One of the chapters in my book, Unraveling U.S. Health Care, which is a guide to the health care system, addresses surgery and tips on how to vet your surgeon and find the optimal facility.
Finding a Surgeon
The best web site for researching surgical specialties is the American College of Surgeons, which allows consumers to look up surgeons by specialty and location. The web site for this is: For instance if you need a neurosurgeon, you can enter that and voila, the universe of neurosurgeons is revealed. These specialists are typically associated with university medical centers and large trauma centers. However, it is amazing that some health care consumers still think that neurosurgeons are available at rural 25 bed hospitals. Even if they were, why would you want to have this type of surgery done at that kind of facility?
Hospital Safety Rankings
Secondarily, it is worth your while to review hospital patient safety ratings before deciding on the facility. Methods to discern patient safety ratings of hospitals include reviewing the published information on, by going to the 2010 hospital survey and looking up your state and the targeted hospital. Another method is to go to the federal Health & Human Services Agency web site for comparing hospital performance. It allows you to look at multiple hospitals at once. The web address for this is and the site was recently updated to make it easier for consumers to use.
Reporting of Hospital Medical Errors
Another important aspect of doing your due diligence before undergoing surgery is reviewing patient medical errors and whether or not your state shares this information with the general public. Let me save you the time on this one, as I have reviewed all fifty states and the District of Columbia and the only states which required public reporting of hospital medical errors impacting patient safety were: Minnesota,Connecticut, and Indiana, The following states collect the data but do not necessarily make it readily available to the public or the data is not facility specific: Colorado, Illinois, Maryland, Massachusetts, Michigan, Missouri, New Jersey, Oklahoma, Oregon, Pennsylvania, Rhode Island, Tennessee, Utah, Vermont, Washington, and Wyoming. I will also mention California, but they have been criticized for not complying with a state law on the reporting of hospital patient safety data. Scarier still is the 2005 Montana Law that has been dubbed the "I'm Sorry Law" giving health care providers additional protections for adverse patient safety events. Though Montana is rural and retention of some clinicians may be an issue, it is still of concern when in 2003, they repealed the requirement for a statewide health database and now clinicians are given more protections than patients.
In terms of preparing for any surgical procedure, it is most important to select the surgeon and the facility, but also to verify the accuracy of the diagnosis, so getting second opinions are a good method if you have any doubt. However, given today's digital imaging, it is much easier to see clear images of tumors and other issues than in 1993 when I had my first big surgical event. So verification of the diagnosis is key.
Once the diagnosis is determined,the treatment plan needs to be discussed and planned. Adverse events, post surgical recovery, and rehabilitation need to be considered in any plan. I suggest using a healthy level of detachment and planning your surgery like a project.
Presently an agent is reviewing my consumer opus: Unraveling U.S. Health Care: A Guidebook to the Complex and Confounding U.S. Health System. I hope to have the publishing path decided soon and of course, I will keep you posted.
Ending with my usual penache the healthpolicymaven suggests that having surgery done at a local facility, one where it is easier for friends to visit, or with a clinician you like are not enough evidence to support a decision potentially involving your health and well being. Take the time to look up the data, as reviewed by independent third party nonprofit organizations or a government agency under the Health & Human Services arm.
And finally, to the douchebag patients who criticize surgeons for not giving them a back rub and serving as their psychologist, that is not his or her job. They are skilled at cutting you up and putting you back together quickly and with low margin for error, so forgive them if they took the cram course in bedside manner. For oncologists, whose relationship with patients is typically long-term the consultative manner of the M.D. is more important. Having had a few surgeries myself, I do not go into the operating theater thinking I am special, but I realize I am one of many in the sea of humanity and many whiny consumers would do well to consider this perspective. It doesn't mean you take less care in your research, preparation, or recovery from your surgery, it just means, have a little consideration for the brilliant hard working medical staff, especially the surgeons.
For an advanced peek at my guide to the health care system, you can read part of it on:
And this is your healthpolicymaven signing off.

Saturday, June 11, 2011

Health Insurance Premiums and Government Oversight: Consumer Implications from the Affordable Care Act Implications

Government Oversight of Private Insurance: What it Means for the Cost of Your Health Insurance
The plethora of health care laws passed in 2010 under the Affordable Care Act,include provisions for “rate setting” and monitoring of private sector insurance plans on a federal level. The ruling applies to all insurance plans which participate in any government funded health care program, including Medicare, Medicaid, and the soon-to-be-deployed regional insurance exchanges. This article explains how this differs from present rate monitoring and premium-setting and the ultimate impact on the consumer.
The Rules
Health & Human Services is charged with establishing a health insurance rate oversight committee, to assess the reasonableness of proposed health insurance rate increases starting in 2014. Since health insurance premiums have continued to grow at a rate in excess of inflation and increased 41% between 2003 and 2009, according to a Commonwealth Fund study , affordability is a concern. The federal PPACA law mandates health insurance as a means to providing national health care, so the viability of the national health care program depends on manageable health insurance premiums for the private sector.
Current State
Insurance premiums are determined based on each state’s rate authorization standards with the Insurance Commissioner, who is an elected official. Some states have a “use and file” policy which means the insurance company can decide to make plan changes, adjust the rates, and start implementing before the state approves them. Other states have a “file and preapproval” policy, which means you have to get the state office to approve of your math, the reasons for your plan increase first. The insurance company then has the opportunity to comment and either accept the commissioners regulations or withdraw the product. In the case of Principal Financial Group, when a previous Washington State Insurance Commissioner mandated that all individual medical plans provide maternity coverage and other provisions, they pulled their product from the state. In economic terms this is referred to as an unintended consequent of a regulatory action. The federal government does not have the authority to control state insurance premiums for the private sector. Medicare and Medicaid plans are of course, a different story as they are government plans.
Altered State
Through the process of gathering data, analyzing cost impacts, discerning patterns, and revealing information to health care purchasers, both individual and corporate, Health and Human Services, which oversees the Centers for Medicare and Medicaid, is charged with creating a more transparent process for what you actually end up paying for medical insurance. The intent is good, but there is no regulatory authority to enforce rate fairness by state and a regulation without enforcement can be problematic. Finally, the cost of the regulation will be borne by the private sector rate payers, which will add a nominal cost to individual premiums, spread over the entire population.
Economic Impact
I spoke briefly of unintended consequences above, but let me restate, if an additional regulation means more insurance companies will cease to offer insurance plans to the small group and individual markets, this may not be a good thing for consumers. Of course, the insurance industry is already seeing a reduction in the number of companies offering medical insurance and this trend has been going on since I was in the benefits business in the 80’s and 90’s. In short, private sector companies, both for-profit and not-for-profit will make market decisions based on where their strengths lie and act accordingly. And one could argue that as long as the companies which remain are of quality and offer good consumer products and services, this change is not untenable. The Netherlands and Switzerland both have private sector insurance programs financing their public health plans and only a hand full of companies provide the coverage, which seems to work fine. Also, they pay much less per-capita for health care than the United States does, but the healthpolicymaven has told you that before.
What it Means to the Health Insurance Premium Payer
OK, here is the “skinny” on this one, since the federal government Does Not have rate setting authority for insurance, which is controlled by each state’s elected insurance commissioner and those state administrators, this change will not have a direct impact on the rates you pay for medical insurance. What is more, since it is highly unlikely the government will be able to overturn ERISA or the McCarran Ferguson Act; don’t expect to see any rate relief. ERISA is the Employee Retirement Income Security Act which created the exemption for self-funded or self-insured plans, which most major employers have used to exempt themselves from many state and federal mandates. I do not see the government succeeding in overturning this act either. The McCarran Ferguson Act is a federal law which gives states the authority to regulate insurance. It should also be noted that insurance premiums taxes are a major source of funding for the states and they will never give up that revenue. Indirectly the fact the government is requiring the disclosure of the rate factors and will publish the information is a good thing for consumers. You will no longer have to be an insider in the insurance business, which you know I was for a couple of decades, to understand this process. In conclusion, will this make your insurance cheaper, no, because that depends on many complex factors that have to do with underfunding of government programs which the private sector has to support with cost transfers, market supply factors, and the degree to which primary health care is deployed in this country. Finally, people will still have to care enough to read about the provisions and many people don’t. The healthpolicymaven’s book, Unraveling U.S. Health Care should come out later this year and it is a guidebook to our health system, in lay person’s terms, which I am hoping will facilitate more outreach in this area.

Friday, April 29, 2011

Accountable Care Medicare Shared Savings Rules and How they Benefit Consumers

Accountable Care Organizations and Medicare Shared Savings Program
The federal Department of Health and Human Services (HHS), which includes the Centers for Medicare and Medicaid Services (CMS), announced proposed rules for the much vaunted Shared Savings Program for qualifying Accountable Care Organizations on March 31st. What struck me about the program, was how much of the risk management formula was taken directly from the private insurance sector, which is an indication of a public/private hybrid for program management. Since it is my belief that we can provide optimal public services through this model, I am keen to evaluate, follow, and measure the results for this revolutionary change in health care delivery for Americans. This article explains the risk sharing mechanisms in the new program and what it may mean for consumers.
Private Sector Influence
The Centers for Medicare & Medicaid, which administer the largest health care program in the country, have created a health care program, called Accountable Care which requires clinical results within a certain range in order to get optimal reimbursement levels. Additionally, organizations which outperform the government set standards have an opportunity to receive a gain or a share of the unused funds. In the insurance business this is called retrospective financing, where the provider reimbursements and participant insurance rates are established based on certain assumptions by actuaries at the beginning of the plan year. About three months after the close of the plan year a final report is given, which illustrates the true performance compared to the expected levels. At this time the corporate insurance client either owes money or has a credit toward the new plan year. It is this type of accounting that CMS is using to gauge the “Shared Savings” for ACO participants. But before we examine the shared savings program let’s briefly review what it takes to qualify as an Accountable Care Organization.
Eligibility Rules for Accountable Care Organizations
Who is eligible to be part of an ACO? All clinicians in group practice arrangements, networks of individual practitioners, joint venture partnerships with hospitals and other professionals, hospitals who employ ACO professionals, Critical Access Hospitals, and any health care practitioner or entity receiving Medicare reimbursements for services are eligible for ACO status.
Potential Roadblocks in Achieving ACO Status
Rural and semi-rural areas may have difficulty with the ACO status (Wenatchee Valley Medical Center for eastern Washington comes to mind) because anti-trust hurdles must be cleared with respect to market share. I imagine the way an organization will address this is to make sure the mix of employed clinicians versus contracted ones meets the 50% or less rule for Primary Service Area standards. It also looks like the non-urban exemptions and critical access rules will allow organizations like these to qualify.
All organizations who wish to participate in the ACO program must maintain a minimum level of patient volume of 5,000 patients.
The Accountable Care Agreement is binding for Three Consecutive Years
Organizations participating in the ACO Shared Savings Program have a choice of two models, either the one-sided or two-sided version. The names are humorous to me, but let me explain where they come from in terms of insurance risk management programs. The one-sided program means the organization shares only in the “up-side” or gain for performance improvements under the contract. However, CMS always likes to be a little different and this more limited risk exposure is just for the first two years, after which the organization experiences the full risk sharing. The “two sided” model means the organization is exposed to both gains and losses from the beginning of the three year contract. This seems like a no-brainer, why would a clinic want to be on the hook for losses right away in a new Medicaid program? However there is more to it than that, because the potential for gain differs.
Government Incentive for Meeting Benchmarks
Using a complicated formula of a per-enrolled-patient-risk-adjusted cost benchmark CMS has created a financial incentive of 2% to 3.9% depending on the number of patients involved in the ACO. In my previous ACO article in September, I highlighted some of the clinical outcomes the agency was seeking, to be eligible for the shared savings. CMS has identified 65(yes, it is complex) quality measures in these five areas under ACO provisions:
1. Patient/caregiver experience
2. Care Coordination
3. Patient Safety
4. Preventive Health
5. At-risk population/frail elderly health

Conversely, in terms of shared losses, the organization’s cost basis must be 2% or more over the cap to be required to pay CMS a differential based on ACO patient performance. What is important is that the participating ACO organizations report their quality metrics using the Medicare Physician Quality Reporting System (PQRS) and also using an electronic health record or HER or EMR. This incentive system will allow Medicare, the administrator for the largest health program in the United States to make assessments and extrapolate information on its population, for better program management. This is a great thing for the consumer, which is anyone who is on Medicare now and all of us who are paying for Medicare. There is also an additional incentive to use the Medicare reporting system which is the equivalent of one half percent of the total clinician’s billing to Medicare for each eligible professional’s Medicare Part B fee (out-patient doctor’s visits). This is significant and should encourage providers to participate in the program. Another ACO rule states that at least 50% of primary care physicians must be users of a certified electronic health record by the beginning of the second year of the contract. (Tremendous opportunity for EMR companies). Another aspect of the ACO rules is public reporting of some of the quality measures, which will create a nationwide standard for health care quality measures.
The Centers for Medicare and Medicaid Services has anticipated that some organizations will have difficulty meeting 100% compliance, so they have a Corrective Action Plan process. The CAP process includes noncompliance warnings, special monitoring, and a formalized corrective plan. If an organization fails to meet the ACO compliance rules and is removed from the program, it must wait three years before re-applying for participation. The review process for noncompliance is rigorous and participating organizations must submit to period audits.
Consumer Benefits
One of the positive aspects of ACO reporting is the data which will be gathered in a standard format and shared in aggregate with participating Accountable Care Organizations. There are also methods to coordinate with other Medicare Demonstration Programs, to avoid “double-dipping.” Other Medicare Demonstration Projects include: the Independence at Home Medical Practice Demonstration, Medicare Health Care Quality Demonstration, Medical Home Demonstrations, Physician Group Practice Transition Demonstration, Community Home Health Teams supporting Patient-Centered Care, and various state initiatives supporting Medicaid patients with chronic conditions.
Conclusions for Consumers
The ground breaking requirements of the Accountable Care Organization Rules enacted in 2010 are the result of a peer review process since the International Order of Medicine’s infamous report on the poor patient safety record in many United States health care facilities. Consumers will start to have access to standardized reports on participating health care facilities clinical safety measures and patient care data. This is a tremendous step forward for American consumers, as transparency in reporting is one of the hallmarks of high quality organizations. Integrated health care organizations like Virginia Mason already provide detailed patient quality information and the CMS Shared Savings Program will help others achieve similar reporting and patient quality standards. This is an example of good governance at its best, with an incentive to respond to the consumer push for greater efficacy in patient care.

Tuesday, March 22, 2011

Hospital Quality-Checks & Balances

Discerning Hospital Quality
The Center for Medicare and Medicaid Services(CMS) now requires health quality measures for specific clinical services, in order to recognize and encourage the best patient outcomes. Recognition will include greater financial reimbursement for those medical practices which conform to the CMS standards for clinical outcomes. This is yet another step in the right direction toward patient-centered-care as identified by the International Order of Medicine. This article highlights the primary hospital quality watchdogs in the United States and consumer tips on how to assess your hospital.
Organizations Measuring Hospital Quality
There are a number of ways to gauge your hospital’s quality, including accessing information from public sites, such as the Center for Disease Control, the Center for Medicare and Medicaid Services and the Health & Human Services Agency. There are also nonprofit organizations devoted to measuring hospital quality including; the Joint Commission for Hospital Accreditation Organization, National Quality Forum,Then LeapFrog Group and the Quality & Patient Safety Organization. Here are the crib notes for these organizations.
Private Sector Quality Watchdogs
Joint Commission
The Joint Commission for Hospital Accreditation is the pre-eminent organization for auditing and certifying hospital services in the United States. Obtaining its’ certification is an essential requirement for hospitals, which may lose reimbursement contracts and patients without the JCO recognition. The Joint Commission recognizes twenty-two hospital medical errors, which it has been tracking for patient safety purposes for 15 years.
National Quality Forum
The National Quality Forum is a non-profit group created by thirty-two health care organizations to develop consensus about hospital quality indicators and reporting. The NQF reviews twenty-seven patient safety metrics, but the information is not shared with the public.
Quality & Patient Safety Organization
The non-profit Quality and Patient Safety Organization or QuPS provides state-by-state analysis of patient safety initiatives by state governments. You can go to the site and see what your state has done to make your hospital safer.
Public Agency Quality Police
Agency for Health Research and Quality
The Agency of Health Research and Quality or AHRQ was created in 1999 to promote methods for improving health care quality in the United States. Though it doesn’t have any enforcement provisions, it does conduct research, award grants, and recognize health care groups with excellent performance.
Center for Disease Control
The federal Center for Disease Control established the National Health Safety Network in 2005. As of 2010, twenty-two states had adopted this method for reporting patient safety errors in hospitals and other inpatient facilities. Presently, 3,000 hospitals use this system, which make it the largest database for hospital errors in the United States. The data is collected for scientific review and specific facilities are not disclosed.
Center for Medicare & Medicaid Services
The Center for Medicare & Medicaid Services polices patient quality outcomes and publishes statistics, like patient mortality from pneumonia, heart failure, and acute myocardial infarction (AMI). However, mortality information alone is not a good measure of hospital quality or patient safety, because you would have to know the patient volumes as well as the morbidity or overall patient health. This information may be found at:
One of the CMS sites that is helpful is the listing for certified organ transplant centers at:

Health & Human Services
The Health & Human Services Agency or HHS has a web site where you can find your hospital and compare clinical outcomes by diagnosis, to other facilities. This is a useful tool if you live in an urban area with multiple facilities, because you will literally be able to check their performance before your procedure. The link to this site is:

Other Public Sources for Hospital Certification Information
The American College of Surgeons publishes an on-line guide to Trauma Center Certification which is quite detailed because it explains the criteria for Level I Trauma Status. Also, university hospitals are teaching facilities and they typically have the highest status for trauma injuries. Information on your university hospital is available on its web site or through the State Department of Health.
Local Look
Washington State Hospitals which scored high in quality measures for 2009 data include: Virginia Mason, all of the Swedish Hospitals, University of Washington Medical Center, Harborview, Northwest Hospital, Seattle Children’s Hospital, Kadlec Hospital, St. Claire Hospital, and Mary Bridge Children’s Hospital. For information on how hospitals fared in your area, contact the healthpolicymaven by scrolling down to the comment tool or complete the form at:
Consumer Tips
The healthpolicymaven’s advice is to know-before-you-go for your surgical procedure and here are some helpful tips to figure out your hospital's quality score:
1.Look for public reporting of hospital medical errors as this is the highest degree of transparency and commitment to improve patient safety.
2.Hospitals which use a national model like the CDC’s National Health Safety Network are using a rigorously tested assessment model.
3.Find out if your state mandates public disclosure of patient safety errors and if it is available by facility.
4.The Center for Medicare & Medicaid publishes information on hospital performance, including infections, surgical errors, and discharge information.
5.Ask questions and do some research.

Closing Thoughts

This patient safety article may not seem that germane now that the country is in its third war and on its knees fiscally. However, the Chinese are paying our light bill, having mastered science and math and access to birth control. Meanwhile folks in the United States continue to debate teaching the science of evolution versus the dogma of religion in public schools. Is it any wonder the US doesn’t measure up to global standards for primary education?

Sunday, January 30, 2011

Amending the 2010 Health Care Reforms Checklist

Suggestions for Amending the 2010 Health Care Reforms
Now that the teeth gnashing is on-going over proposed changes to the health care reforms of 2010, this article addresses some areas for potential modifications. If any of you are under the delusion that everything will be repealed, wake-up, because the Medicare changes are essential to management of that costly federal entitlement program. I am speaking of the pay-for-performance initiatives where Medicare (Center for Medicare Services) pays more money to organizations which have fewer medical errors and re-admissions for patient procedures. I am referring to the Accountable Care Act will have a major impact on how medical care is organized, models for disease interventions, and the reporting of performance metrics(I wrote about this last fall). So, that stays, but the rest of this article addresses some of the things that could go or at least be modified.
Federal Insurance Purchasing Subsidies for Mandated Health Insurance
A few months ago I did an analysis of the federal insurance purchasing subsidies for the middle-class under the Health Care Affordability Act and it was pretty eye opening. Based on World Bank data the mean income in the United States is $47,240, which is the average income per person using 2009 Gross Nation Income data . Using this average income as a starting point, what kind of a subsidy would someone receive in 2014, when the insurance exchanges are in place and medical insurance is mandated? Families with seven or more children and incomes equal to 133% of the federal poverty rate will receive a federal subsidy equal to 97% of the insurance premiums. This seems fair to me, as that is a modest income for a huge family. However, the federal subsidies also are slated to provide assistance to folks who fall within 400% of the federal poverty level, which can be a very decent income. For example, someone who is single and earns $54,120 is eligible to receive 90.5% of their insurance premium paid for by the federal government. First of all if you are single and have that much income you ought to be able to scrape by. Secondly, this income is higher than most of the world averages and higher than the USA’s average per capita. But it gets worse, based on the 400% of Federal Poverty Level criteria people who earn up to $185,160 are eligible to receive the same federal subsidy if they have at least eight children. Now, I think by anyone’s standards someone with that income, which falls into the top 10% of all incomes in the country, is not poor. I can see giving a subsidy to a family of four with the $54,120 income or even higher, but not over $100,000!
Budget Saving Suggestion
Here is my suggestion, only provide medical insurance subsidies to people who earn up to 150% of the mean national income, which equates to $71,131 and is roughly equivalent to $73,835 for a large family in the federal poverty criteria. For people who want tax subsidies for families earning over $100,000 I say start eating beans or tuna noodle casserole, which I ate a-lot-of as a child.
Possible Places for Federal Budget Cuts
For crying out loud, it would be nice if both parties could focus on the real apocalyptic events for the country, such as the fiscal meltdown from a strong country with reserves to the largest national debt in history in eight short years. The real concern should be reducing the national debt by cutting spending so the country will have to do less begging for financing from China and other creditors. According to the non-profit Kaiser Foundation, 40% of the entire 2010 federal budget was for defense spending. To decrease that by 50%, just cut the discretionary defense spending budget which equals nearly 20% of the entire federal budget, and we can get the country back in fiscal shape in no time. The country needs to find a way to pay for its existing programs, like Medicare, Medicaid, and Social Security and reducing spending on other ones is required.
Of course the Medicare expenses are of concern and the changes to the program in 2010 are a start towards reworking that care model. The USA will move to a Medicare model which provides services for the treatments that are most effective and hopefully pays the physicians a decent fee. There is still much to be done on aligning clinical reimbursement in both the Medicare and Medicaid programs. The latter is very onerous, because the federal government dictates Medicaid benefits but provides grossly uneven support to the states which are charged with administering the program.
Focus on the Real Issues which have significant Cost/Benefit Ratios
It would be nice if the Democrats would quit focusing on who-is-shagging-who or what someone’s sexual orientation is, because I really don’t want them to tell me about it. As long as it isn’t a crime (certain southern states excepted) I don’t need to hear about it and this goes for anyone’s sexual persuasion, I don’t care to hear about your predilections. I prefer to focus on issues we have in common, such as education, health care, and oh, not-going-into-the-poor-house as a nation. Don’t ask, don’t tell, don’t care is where I am at in this tired issue.
Republicans, I am tired of having abortion as such a divisive issue and I question whether the paltry amount of federal money that is actually spent on abortions for Medicaid women who have been raped (one of the criteria) is the real problem. What would it take to make you folks quit yapping about this issue, a total ban on federal money? The big stink made about offering birth control options, not just abortion in the federal insurance exchanges far exceeds the estimated $1 cost-per-head factor for this provision. Although I think it is immoral to prevent poor women from seeking birth control options which are legal, I believe the rational and generous people of this country will rise to their aid through contributions to Planned Parenthood and women's health organizations. Of course I know the right wingers will still flail away state-by-state (I reported on this in a July article for an east coast distribution and in my November blog about state appeals to the health care reform mandates) attempting to demonize women who seek medical procedures for which they do not agree. We can at least aspire to have a more effective and civilized national conversation about resource allocations.
Current focus on re-defining rape is actually part of the Republican Agenda in Congress
It would be nice if the vagina control police would spend less time defining what constitutes the a rape of a female, thereby qualifying her for federal funding for an abortion under the tan-your-Hyde Amendment, and focus on delivering cost effective primary care to everyone. The discussions on whether drug or alcohol induced sex with an incapacitated female constitute rape are too prurient for this voter. To say nothing of the “men's room chats” about redefining what is considered incest in the case of sexual intercourse. In other words if your uncle coerces his thirteen-year-old-niece to have sex with him and she gets pregnant that may not be considered rape unless other physical violence was involved (barring rape or incest the girl would not be eligible for a federally paid abortion). Also, since when are thirteen year-old girls women? The marginalizing of women in America is in full force, what is next, wearing burkas?

This article was written by Roberta E. Winter, MHA, MPA a health policy analyst and independent journalist and may be reprinted with her permission.