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Wednesday, December 31, 2014

Reviewing Centers for Medicare and Medicaid Incentive Programs

As 2014 fades from view, I am barely making my monthly deadline for the Straight Talk column. but I would like to leave you with a couple of thoughts for the new year. There have been more than a few articles detailing the Centers for Medicare and Medicaid (CMS)grant awards as well as enforcement efforts impacting your health care. First, let's start with the positive, CMS provides grant awards for government agencies as well as multi-agency initiatives to study ideas for improvement of health care. In 2014, these states received grant awards for initiatives to better resource care for Medicare, Medicaid, and the Children's Health program: Arizona, California, Colorado, Connecticut, Georgia, Florida, Illinois, Iowa, Kansas, Maryland, Massachusetts, Michigan, Minnesota, Nebraska, New Hampshire, Mexico, Ohio, Pennsylvania , South Dakota, Texas, Virginia, Washington, and Wisconsin. Washington State has received a 65 million dollar grant, starting February 2015, to work with government and private sector health care providers across the state to look at methods to reduce administrative redundancies, eliminate unnecessary costs, and strive to improve health care. So, congratulations to Washington for going after the grant, which is a multi-year laborious effort, and for winning it! The venerable Washington Health Care Authority will be in charge of the project, which is the same agency which has run the State Employees Health Plan for decades and also implemented the Health Insurance Exchange. For more information on the type and amount of the award follow this link to the CMS site:

Scale of these Government Funded Health Care Programs
To give you an idea of the scale of Medicare, it represents 12% of the entire federal budget. Medicaid and the Children's Health Program represent 8% of the nation's budget, but remember these programs are also funded by the states. According to the Center on Policy and Budget Priorities, the 2013 budget allocated 22% for these three programs, which is a significant increase over 2010, when the total was 20% for these three programs. For more information on this you can follow this link:  Just to keep this in perspective, defense spending was 19% during the same time frame. CMS is the primary government authority charged with administering these programs, as well as performing investigations into health care innovations. And finally, a huge aspect of CMS's role is to police the payment system and stop abusive practices.

Accountable Care Organizations
Under the Affordable Care Act, the Centers for Medicare and Medicaid are charged with implementing the Accountable Care Act, which specifies performance indicators linked to government payments for health services. In a recent report, 2, 225 hospitals, which represent about one fourth of the nation's hospitals, are going to experience reductions in CMS payments because they didn't meet the standards. Now, in the private sector, this is referred to as a performance agreement and if a contractor doesn't hit his target, he gets dinged with a penalty. However, this is a new aspect of publicly funded health care. A 2% penalty is also huge, because as you have already observed, CMS provides anywhere from 20% to half of some of these hospital budgets. For example, trauma center and public hospitals, like Harborview Medical Center, in Seattle or Bellevue Hospital, in New York, serve a much greater population of low-income patients, so government funding provides most of their budgets. Though hospitals are concerned about the penalty assessments, the program appears to be working, because penalties are down nationally by 4% overall for 2013, compared to the previous year. And let's give credit where it is due because 1,154 hospitals, which represent about 10% of the nation's facilities, did not get fined. This means they met all of the Accountable Care Organization targets, including reducing re-admission rates. For more information on this program go to Kaiser Health at:

Concerns About Cost Punish Clinicians
One of the consequences of the cost reduction efforts, which are certainly needed, is that clinicians who treat these patients are not getting paid enough, especially for Medicaid. This worrisome trend has continued in a downward trajectory for years. Presently, only 46% of doctors will accept Medicaid patients nationwide. Further, by punishing safety-net hospitals, like Harborview, we are making it even harder for low-income folks to access health care. It seems to me if CMS decided to pay even a modest $10 more per patient visit for Medicaid, this would help offset the dearth of providers for Medicaid patients. At the end of the day, it doesn't matter how fantastic your grant program is if the people who are supposed to benefit are unable to see a doctor. Access to health care is really the issue. Meanwhile, the medical device companies are lobbying their way through Congress trying to get out of their lousy 3% assessment to fund their part of the Affordable Care Act, while they charge Americans 40% more for their equipment than they do other nations. Here's a thought, let's use all of that 3% to provide money for primary care clinicians to serve Medicaid patients. In fact, I suggest you contact your Congressman or Congresswoman and lobby for this provision.

This is the healthpolicymaven signing off, wishing you a healthy new year. For more information on my work, you can also follow me on TUMBLR or Twitter. In 2015, I will be offering some new services as well.

Thursday, November 13, 2014

Non-profit is Not Synonymous With Good Health Care-Anti-Consumer Practices at a Federally Subsidized Clinic

Non-profit is Not Synonymous with Good Health Care-Anti-Consumer Practices at a Federally Subsidized Community Health Clinic
On October 31st, I took my teenage son to Peninsula Health Clinic in Bremerton, for evaluation of a clinical intervention for depression. My regular readers will recall the trauma center blog I posted in October 2012, when my son was hit by a pickup truck and sustained a traumatic brain injury. Head injuries can take a long time to heal and depression often follows. As a healthcare advocate I am compelled to share my experience to illustrate the complexity and failings in primary care in the U.S.A.
Teen Denied Care at State and Federally Financed Community Health Clinic
Arriving at the health clinic after a 2 hour commute walking and via public bus in a driving rain storm, I went to the counter to get my son checked-in for his appointment. There was no queue of patients standing in line, and I was informed we were 6 minutes late for our appointment. I explained that we had traveled by bus and we got to the clinic as soon as possible, and we were still within 10 minutes of the scheduled time. After several minutes, the administrative staff informed me that the doctor was unwilling to see my son, even though he was not a new patient and this had been his primary health care location for over 5 years. At this point, I was incredulous that we were being urged to leave and stated my son was there for evaluation for depression, which had been discussed with the school nurse. What happened next will floor you.
Clinic Staffer Encourages Dumping Practice of Referring Patients to the Local Hospital for Non-Emergency Treatment
Peninsula Health Clinic which actually denied care for my son, which was not of an unusual nature, encouraged us to use the emergency room of the local hospital. My son’s health did not merit an emergency intervention, which is why we were at a primary health care clinic or in layman’s parlance, the doctor’s office. This behavior is referred to as “dumping” when patients are unable to get care at appropriate primary care facilities and sent to the ER of hospitals. In Chapter 9, of Unraveling U.S. Healthcare-A Personal Guide, I explain how people in the United States should access health care wisely from an economic and health outcome basis. The emergency department of hospitals is the most expensive place to obtain primary health care and is thus to be avoided. Patients are often derided for over utilization of the “ER”, but there is more to this picture than meets the eye, as the options for obtaining health care are limited in many areas of the country. If the clinics which receive government funding to provide primary health care are insolent and unwilling to serve their community members, what choice do these folks have but to go to the hospital? In my son’s case we elected to defer treatment because he had to get back to school. As a parent I am concerned about his health and we do have a follow-up appointment scheduled at Seattle Children’s Hospital In December.
How Money Impacts Treatment
Peninsula Health is a designated federally qualified health center located in Bremerton and other sites in the county.[1]  In 2014, Peninsula Health received $1,572,083 from our federal government to provide primary health care.[2] This means that the clinic is charged with serving patients who may not have access to other health care options or for which there are obstacles, such as lack of transportation, or clinicians who refuse to treat them.  The community of Bremerton has a disproportionate share of low income residents, in large part due to zoning laws which allowed less restrictive housing per parcel from World War II. Harrison Medical Center is the hospital for nonmilitary personnel in Bremerton and the Franciscan Order, which acquired the publicly financed facility wants to close the hospital. The reimbursement mix just doesn’t work for their bottom line, religion or not.  Consequently, the ability to obtain health care for those who are most in need is becoming more tenuous in this community. As a federally funded facility the clinic must adhere to certain practice standards, which in theory, should provide basic or primary health care more effectively than other options.
As a healthcare insider some of you may wonder why I choose Community Health Plan’s Peninsula Health Clinic and the answer is, we ended up there as a last resort. Briefly, over the course of the past eight years the following circumstances gave us no choice but to use the Sixth Avenue Clinic or take the longer commute into Seattle for health care: 
  1.   In 2006, when my son and I relocated to Bremerton, largely due to the walk-on ferry access to Seattle, we initially sought care with a private practice physician. With each appointment the doctor complained about his reimbursement, the staff wasn’t very nice, and getting there required a 10 mile round trip bike ride and a ferry trip to Port Orchard. Still, we persisted until the clinic was closed, meaning the doctor moved his clinic to a more lucrative location. 
  2. When my son was in middle school we sought family health care in a neighboring community, but found the transportation options unworkable. 
  3. Services to deal with pediatric or youth depression are extremely limited in Kitsap County, yet the State of Washington under Senate Bill 6312, has just approved a new plan to make the entire Olympic Peninsula and Kitsap County one service area.[3] The few services available for mental health are for adults and drug offenders in the area. My son and I have found it more efficacious to spend 2 hours on the ferry and 1 ½ hours busing to appropriate services in Seattle, for which I have paid 100% of the cost out of my pocket, as it is deemed out of our service area. 
  4. Given that my son was in grade-school when we moved here, I felt it was prudent to seek health care that was local, hence the Sixth Avenue Clinic, located less than two miles from our house.
Increasingly Those Providing Primary Health Care Are Getting Squeezed
Firstly, we don’t have enough primary clinicians in the United States, so this creates a problem with patient access. Secondly, there is high employee turnover in health care, which exacerbates the problem. Thirdly, clinics serving a higher proportion of low-income patients are dealing with grittier issues than in more affluent areas. It all comes down to the money, Medicaid doesn’t pay enough for 46% of the doctors to accept Medicaid patients.[4] This means federally qualified clinics, public health departments, and the public emergency room are where patients seek care.  But the fiscal situation of the clinic is not the fault of the patient, nor should patients be refused treatment.
What You Should Do To Advocate for Your Child to Get the Health Care They Deserve
Fast forward, Peninsula Health sent a letter to our house indicating my son was a no-show for his appointment, which of course was not true. As your advocate for patient rights, here is what I did; composed a single page letter with our grievance on patient care, sent it to the local clinic-Peninsula Health, to Community Health Plan of Washington the affiliated insurance provider, and to the State Medicaid office which provides funding for the clinic. Next steps- to date there has been no written response from any of the clinic representatives, because they are demanding a HIPAA form be completed first. If getting refused for health care doesn’t kill you, the paperwork will.
A Little Respect
Having commuted by bicycle and public transportation in multiple locations since 2003, my son and I have learned to be resourceful, which is not always met with appreciation by health care providers. In an era when a third of the nation’s children are overweight, getting regular exercise is the surest way to maintain a healthy weight. And I am happy to say, I do not take any medication, because of my diet and exercise regime. We are doing our part not to add to the burden of the U.S. health care system, so rather than being treated with derision, how about encouragement. Though I am loathe to share personal information, this situation really shows how people are dumped in the health care system and it is even worse for those patients who lack my education and tenacity. As for the clinic admissions representative who refers to me as “the mother,” even Safeway personnel manage to get my name right and add a salutation. Yes, I am “the mother” who will stop at nothing to assure my son and others like him get decent health care because that is the right thing to do. 

This is the healthpolicymaven signing off, encouraging all of you to resource your health care wisely and stick up for yourselves. Don’t think that everyone behind a desk has your best interests at heart. Feel free to share this article virally but please provide appropriate attribution to the author and Praevalere!

For more information on federally qualified health centers and other resources read my book which is found in public libraries throughout the land and of course, on Amazon, ranked #35 for health and medicine books.

[1] *Peninsula Community Health Services is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).

Sunday, October 26, 2014

Hospital Safety In Light of Ebola Scare

Hospital Safety In Light of the Ebola Scare

Due to public hysteria and resulting quarantine for Ebola patients, family members, and anyone who may have come in contact with any of these unfortunate individuals, this is a good time for consumers to re-acquaint themselves with patient safety standards through publicly available sources. First a primer on the main causes of adverse patient safety events in hospitals in the United States. In patient safety lexicon when something goes wrong in health care treatment while in a hospital setting, this is referred to as an adverse event. There are a number of health care organizations within the nation that track patient safety information including: the Centers for Disease Control, Joint Commission for Hospital Accreditation, the National Quality Forum and several nonprofit entities. Of the nonprofit leaders, The Leapfrog Group® is known for its annual hospital quality and patient safety survey, of which over 5,000 hospitals participate. In addition to this, the Commonwealth Fund[1] has also published patient safety and health care outcome information, including the average number of safety events by category and by county.

A detailed analysis of patient safety tracking entities is provided in Unraveling U.S. Healthcare-A Personal Guide[2] and no less than three chapters detail hospital quality and patient safety, by facility and by state. However, since this is a monthly health care column and not a book, I am using Hospital Safety ScoreSM, The Leapfrog Group® annual hospital quality survey to highlight how hospitals rank which are handling Ebola patients[3]. This is meant to provide consumer information on basic patient safety rankings, so that the informed patient will use sound information and not hysteria when making health care decisions. To that end, here are the rankings, starting with Dallas Presbyterian Hospital:

Dallas Presbyterian Hospital Survey Results as of August 2013[4]
Infection rates observed in patients versus the expected rate are listed below for two common metrics
Central Line Infection Rate is .56, which nearly matches the national average of .55, which is a solid performance.
Catheter Infection Rate is .19, which is far better than the average rating of .71 for the survey respondents.
Patient Safety Processes
Computerized Order Entry-100 (out of 100)
Physician Staffing in Intensive Care Unit-100 is a perfect score
Identification and Mitigation of Risks-120 (out of a possible 120)
Hand Hygiene-30 (out of a possible 30)
Nursing Workforce-100 (out of 100)

By all measures Dallas Presbyterian Hospital is a top-notch facility in terms of patient safety, but the Ebola patient who died was treated too late, and time-to-treatment is a key statistic for improving patient survival in many clinical interventions. Additionally, the man was autoimmune suppressed and taking medication for HIV. The laboratory delay was not the fault of the hospital, which used normal protocol, but reflected the dearth of resourcing from a disease prevention level at the Centers for Disease Control and Prevention.
Only the best hospitals are now accepting Ebola patients, those trained for the most acute care, including the venerable Bellevue Hospital in New York City, Harborview Medical Center in Seattle and Emory Health Care in Atlanta. Focusing on the patient safety processes of the Leapfrog survey, here are the scores for these facilities as well:

Note: The [Leapfrog] Hospital Safety Score grades hospitals on data related to how safe they are for patients. For more information, visit”

Leapfrog Group Criteria for Emory Health Care-Atlanta[5]
Central Line Infection Rate-.522 (better than average)
Catheter Infection Rate-1.60 (much worse than the average reported of .71)
Computerized Order Entry-65 out of 100
Physician Staffing in ICU-65 out of 100
Identification and Mitigation of Risks-Did not report
Hand Hygiene-Did not report
Nursing Work force-Did not report

Leapfrog Group Criteria for Bellevue Hospital-New York City[6]
Central Line Infection Rate-.645 (worse than average)
Catheter Infection Rate-.682 (better than average)
Computerized Order Entry-65 out of 100
Physician Staffing in ICU-Categorized a 5 or the lowest score in this criteria, the average facility had a score of 31 and the top hospitals scored 100.
Identification and Mitigation of Risks-Did not report
Hand Hygiene-Did not report
Nursing Work force-Did not report

Leapfrog Group Criteria for Harborview Medical Center-Seattle[7]
Central Line Infection Rate-.46 (better than average)
Catheter Infection Rate-.71 (average)
Computerized Order Entry-50 out of 100
Physician Staffing in ICU-100 out of 100
Identification and Mitigation of Risks-120 out of 120
Hand Hygiene-30 out of 30
Nursing Work force-100 out of 100

Now that the CDC has stepped up its monitoring and support for Ebola, with airport screenings (not sure how effective this will be) and rapid lab responses for blood screenings, it is a good time to review how we resource disease surveillance in the nation. In the case of hospitals, with the exception of the Veteran’s Administration and university hospitals, most are private facilities. This means Texas Health Presbyterian Hospital in Dallas had to shell out the money for extra hazard gear, extra cleaning costs, and extra staffing for Ebola. If we are going to expect a private facility to provide this type of intensive support for prevention of highly contagious and highly fatal diseases, we need to look at how we fund these services. Certainly syphoning new Ebola patients to trauma centers is wise, but that in and of itself is not a cure, more like a Band-Aid.
Regarding the other facilities targeted for Ebola triage, of concern is the poor intensive care staffing score for Bellevue Hospital in New York City, sounds like this place could use an infusion of capital from the big apple. And it should be unacceptable for any publicly funded facility to refuse to provide patient safety reporting information on basic stuff like hand washing, identification and mitigation of safety risks, and their nursing staff standards & staffing (Bellevue and Emory). Finally, thank you to Texas Health Dallas Presbyterian for going first in this fiasco because the nation learned a lot at your expense. Clearly you run a first rate facility, based on your reported patient safety data, so maybe you can petition our federal government’s Health and Human Services for some disaster relief money.

And this is the healthpolicymaven signing off encouraging all readers to share this article virally, but with appropriate attribution for  the author of course. For more information on patient safety, read