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.

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: www.facs.org. 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 www.leapfroggroup.org, 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 http://www.hospitalcompare.hhs.gov. 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:http://www.authonomy.com/books/24823/unraveling-u-s-health-care-everything-you-always-wanted-to-know-about-health-care-but-were-afraid-to-ask/
And this is your healthpolicymaven signing off.

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.

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.

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:
http://www.cms.gov/HospitalQualityInits/20_OutcomeMeasures.asp
One of the CMS sites that is helpful is the listing for certified organ transplant centers at: www.cms.gov/CertificationandComplianc/Downloads/ApprovedTransplantPrograms.pdf

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: www.hospitalcompare.hhs.gov

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: roberta@healthpolicymaven.com
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?

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.

Fatwa on the Fat Wallets; the Dismantling of the Middle Class in America

How the latest proposed tax cuts lead to the dismantling of the middle class in America
President Obama’s latest capitulation to the greed of the Republicans is unparalled in the blatant disregard for the middle class of the United States. In the event you are just coming out of a coma let me enlighten you as to the facts on the Obama Tax Cut Proposal.
Social Security is being Dismantled
The financing mechanism for social security has been cut by 30%; further eroding the ability of this program to provide the funds for those who are retired, disabled, as well as for widows and children. This is not some abstract idea to me, as my son lost his father when he was an infant and it has been a long 14 years of scratching by. In order to pay for the current social security benefits the fund has to borrow money, to the tune of 112 million. The reduction in Social Security funding will mean our children will have to pay higher taxes in the future to make up for the funding shortfall, to say nothing of the fact I have paid into it since I was fourteen years old.
Impact on the National Debt
The United States overspending is financed by other countries, including China, who have now decided that the US debt is not such a good investment and they have raised the interest rate the US must pay (which is akin to a drop in the bond rating of the nation). This country is spending 39% of the entire 2010 annual budget on war and half of that is on a discretionary defense budget; since I no longer have a discretionary budget, I suggest we get rid of that expense and balance the budget like the rest of us.
Impact on the Average American
The impotent rational for the give-a-way to the rich was the extension of unemployment benefits to the 15 million people who are out of work, of which I am one. Why does there have to be a rational when the country is in a depression and job cuts are at every level both private sector and in all levels of government? Once again government is out of touch with the daily lives of its citizens.
According to the latest figures from the World Bank the average income in this country is $47,240 and the tax cuts provide less of proportional benefit to the average American, with $1,000 for those earning $50,000 and $2,000 for those earning $100,000. People who earn the former need the money more.
The entire spend for Medicare and Medicaid health care programs is only 23% of the budget and with current Social Security spending that adds another 20%, for a grand total of 43%. Yes, that is right folks; your government spends nearly as much on war as on all of the benefits, which you have paid for, for everyone else in the country. At least Obama has included health care in the benefit equation, but he capitulated on that too, by letting the insurance lobby create an expensive mess instead of more affordable national health care.
The top 3% don’t need the tax breaks and boo hoo on their estate taxes; they set up trusts, and use insurance to pay that tab anyway. And whatever happened to the adage you can’t take it with you?
Conclusion
It is about time the elected officials in this country started having more respect for the poor working stiffs, who are not getting ahead, instead of catering to the rich, who are obviously born under a different star. So Mr. Obama as you continue to spend 40% of the budget on a war that we never should have entered and dismantle my Social Security benefits, I look forward to opening that can of Friskies for dinner. The dismantling of the middle-class will bring a revolution to this country, for which I am prepared to serve. Ending on a positive note I salute Senator Bernard Sanders of Vermont for his nine and a half hour filibuster decrying the injustice of this tax proposal.

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