You're Killing Us

"You're killing us" should have been the message yesterday when hospital CEOs from around the country met in Washington, DC, for the American Hospital Association's Advocacy Day.  Approximately 200 CEOs met on Capitol Hill yesterday with their Congressional representatives to warn of the impact on the access to the care for our patients through arbitrary across-the-board cuts to Medicare and Medicaid.

Between ongoing state and federal budget cuts, state initiated assessments (taxes) to fund Medicaid, the Fiscal Cliff of a 2% reduction in payments to hospitals, the jeopardy that the Maryland Waiver is currently in jeopardy due to the above-mentioned provider assessments, denied days for care that has been provided due to the picayune documentation requirements of payors, withheld monies as a result of the government's somewhat flawed Recovery Audit Contractor (RAC) process (in this case, money is withheld for care that is provided and then the care has to been substantiated in a long, drawn-out process), the financial impact of these cuts on hospitals will threaten our ability to effectively care for our patients .  Simply put, WMHS waits months for monies that should have been paid but are held usually for what seems to be whatever reason the payor can think of.  Eventually we get paid, but the administrative costs associated with the appeals continue to be a burden on hospitals.  With health care costs running about $1.7 trillion per year in the US, hospitals recognize that change has to occur. 

At WMHS, we have made great progress in keeping patients healthy and out of the hospital, ultimately reducing health care costs.  But, that has happened over the last two and one-half years and we are now finally seeing results.  The payors, including CMS, want us to put cost saving initiatives in place overnight and have them generating results by morning.  Real long-term solutions are what is necessary in order to still provide quality patient care while reducing the cost of that care.

Gender Bias, Really?

I read an article in yesterday's USA Today regarding birth control pills.  I am not a clinician, but I am a husband, a father of two adult daughters, a brother and a son.  The article was actually a debate among physicians as to whether or not birth control pills should be sold over the counter.  Some actually stated that it is a gender bias issue since condoms are available over the counter so why not birth control pills.  Huh?  Unless I am missing something, condoms are applied not ingested.  Seeing what it took for the women in my life to either get adjusted to birth control pills or be informed that they were not a candidate due to risk of blood clots and stroke, in particular, is enough for me to weigh in on the side of "what are you people crazy?".  It is obvious to me that a lot has to go into taking birth control pills and that not everyone is a candidate.  For those arguing the gender bias issue since there is no age restriction on the purchase of condoms, the same would apply for birth control pills.  So, what happens when the teenager who wants to become sexually active buys birth control pills and unknowingly is in a high-risk category for stroke?  The outcome, although more the exception than the rule, is still a bad outcome.  This is really not a good idea and I am surprised that some clinicians are advocating for the change.

Healthcare Keeps Changing

Yesterday through Rumor Control, I heard, according to at least one orthopedic surgeon, that WMHS is now putting restrictions on patients in need of orthopedic surgery.  I can assure you that any restrictions are not from WMHS –they are from those who eventually pay the bill for the surgery.  The payors, particularly Medicare, want to make sure that less invasive treatment and therapy are occurring before the surgeon and the hospital jump right to surgery.  Our orthopedic surgeons have always approached surgery very conservatively.  However, in order to show a robust demonstration of compliance, we now have to document medical necessity prior to surgery through a preoperative checklist.  We have to make sure that conservative treatments were tried and failed for at least 3 months before surgery is scheduled.  Again, this is a requirement of Medicare, not the WMHS administration. 

With all of the changes occurring in healthcare, we at WMHS have to do a better job of educating our physicians and staff as well as our patients.  There are now so many restrictions that are being leveled at hospitals and physicians by the various payors that we need full-time staff just to track the ever changing requirements, such as the medical necessity checklist for hip and knee surgery.

I continue to be amazed at the ways in which the payors, especially Medicare, try to avoid paying providers for care that is delivered.  There are many changes initiated by Medicare that have improved the delivery of care, but there are some that haven't.  Stay tuned.

National Recognition

In yesterday's national publication, AHA News, WMHS was recognized for our RN Transitionist Program.  This initiative was the brainchild of Dr. George Garrow, Chief Medical Officer, and Carol Everhart, Director of Care Coordination, at WMHS.  We now have two nurses dedicated to the program and they visit patients who will be going to a nursing home after discharge.  They coordinate their discharge between the hospital and the nursing home then visit the patient upon their arrival at the nursing home.  The RN then returns on subsequent days to ensure that the patient--now nursing home resident--remains well enough to stay in the nursing home and not be readmitted to the hospital.  Certainly if the resident needs to be readmitted, they are; however, through this program and improved coordination of the patient's discharge, nursing home readmissions have been reduced dramatically.  It is great when our efforts to keep people healthy and out of the hospital are recognized and especially when it is national recognition.  Thank you, Dr. Garrow and Carol. 

Do the Benefits Outweigh the Risks?

Over the weekend, I read an article in the United Kingdom's Sunday Express newspaper.  The article was about the National Health Service in Britain facing a £20 billion (pound) shortfall in its budget and the opportunity to save £3 billion by eliminating physician office visits.  The in-person visits would be replaced with Skype or Facetime between the physician and the patient.  The immediate criticism of these virtual clinics is the inability for those who are technically challenged, such as the elderly or the poor having the ability to access mobile technology due to the cost.  The idea is one that is being borrowed from India, where it is reported to have been successfully implemented. 

From my perspective, the idea is a good one as we are trying such a mobile link between our nursing home and the hospital, but it certainly has its limitations.  Offering the virtual clinic as an option for those who are technically savvy is a good idea, but the complete replacement of office visits is not a good idea.  The risk of missing something via telehealth or mobile technology could be far greater and would be a more significant issue in the US without more comprehensive tort reform.  So, there are lots of benefits with this technology and it should be expanded upon, but not depended upon exclusively.

Just One More Thought...

I know that I said that yesterday would be my last blog until next week, but I had to let everyone know just how popular my daily blog has become.  As I drove past those same bus stops this AM with an outside temperature of 29 degrees, the same kids who were woefully under dressed yesterday were wearing jackets today.  I can only conclude that their parents were shamed into doing something after reading yesterday's blog.  Anyway, it was nice to see that someone had some sense, whether it was the kids who had to be frozen by the time the bus came yesterday or their parents seeing them when they came home from school dressed that way.  All in all, a very good outcome.

As we all prepare for Thanksgiving tomorrow, we have a great deal to be thankful for.  A number of my Facebook friends have been giving thanks each day leading up to Thanksgiving for someone or something in their lives; a very nice touch.  I am especially thankful for my wonderful family, a great health system that I am a part of and a very special community in which I live.  Happy Thanksgiving.

It's 32 Degrees Outside. Where's Your Coat?

I am on  my way to work this AM and pass a school bus stop with high school aged students waiting for their bus.  What I found amazing was that none of them had a coat or jacket on; only one female was wearing a sweater and a thin one at that.  The boys were dressed in basketball shorts and t-shirts and the girls were dressed in jeans and shirts.  How can their parents let them out of the house like that when it's 32 degrees out?  Maybe I am just getting old. But it's freezing!  This was not a lower income neighborhood where affordability could be an issue, but a traditional middle- class neighborhood.  What I find amazing is that the elementary school kids waiting for the bus on days like this are bundled up with hats, coats and gloves; thank you mom and / or dad.  Middle school kids at least have on a jacket, but then there are the high school kids being COOL by having the least amount of clothes on as possible while waiting for the bus.  A minor issue for some, but how are we as health care providers supposed to keep families healthy and out of the hospital when parents allow or ignore what their high school aged kids are doing. I guess better this than a whole lot of other bad behaviors that high schoolers could be doing.

As I take a respite from blogging, have a blessed Thanksgiving and safe travels.

Care Like You Have Never Seen It Before

As I mentioned in Friday's blog, I attended a two-day meeting last week outside of DC on the future of health care.  The one word to describe the meeting would be "WOW!"  As an industry, hospitals, health systems, physicians, other providers and, most importantly, patients are in for quite a change.  As I have blogged in the past, the cost of health care going forward is unsustainable.  Government can't continue to afford the $1.7 billion annual expense of health care.  To put that unsustainability in perspective, if eggs, milk and a bag of oranges had increased in price at the rate health care has since 1945, those eggs would be $55 a carton, the milk would be $48 a gallon and the oranges would be $134 for a bag of 12.

Health care consumers are going to see that they have choices; however, those choices will be similar to when you go to the veterinarian to have your dog or cat treated.  In this case, rarely is there a third party payor involved.  You have a choice for the type and extent of testing, whether or not you would like to have a surgical procedure and what type of supply or equipment that you would like used.  However, as is the case when  you take Fido to the vet, there will be a great deal of out-of-pocket expense for those choices.  For us, a third party payor, whether it's an employer who is self-insured, as is the case at WMHS, an insurance company, or a health care exchange or the state / federal government, will cover care to a certain level, but will not be able to cover all of the health care expenses incurred, especially the "Cadillac" of everything that we have come to expect without some level of sharing on the part of the recipient of the care. 

As hospitals in Maryland, more and more of our payments are now at risk based on the quality of that care; it's called Quality Based Reimbursement.  Hospitals in the other 49 states won't be impacted for at least another year.  We are now directly accountable, as we should be, for reducing infections, the mortality of our patients, reducing admissions and readmissions, the level of satisfaction of our patients, any preventable conditions, over utilization of services, tests and procedures, better and more comprehensive care of our high utilizers of our services to keep them out of the hospital and the list goes on.  Such approaches will reduce the cost of care eventually, but implementing those changes can be very costly initially, as was the case at WMHS last fiscal year.  Health care really is changing and WMHS is trying like hell to keep pace with those changes.  As an industry, health care leaders have to educate their various constituencies as to the changes that they are living with today and those planned for the near future.

When is Enough, Enough?

Yesterday and today, I am attending a meeting outside of DC on the future of health care as a result of the 2012 election.  Actually, I was invited to serve on a panel with the intent of informing health care executives in Maryland, DC and Virginia how WMHS has fared under our new payment methodology.   I informed the group that the Triple Aim of Health Care Reform can be accomplished but it has its challenges. 

During the meeting, I learned from an exchange between the moderator for the panel discussion and former Senator Blanche Lincoln (D -AR), that hospitals and health systems in the US are responsible for complying with 120,000 federal regulations.  I knew it was bad, but had no idea as to how bad.  Now please understand, that doesn't include any state regulations, HSCRC regs for Maryland hospitals or the Joint Commission requirements. Hospitals are routinely criticized for their complexity and bureaucracy; here's the reason why.  No wonder, management guru Peter Drucker says that health care is the US's most complex and challenging industry to manage. 

By the way, former Senator Lincoln was great.  She was charming and engaging and I wouldn't hesitate to vote for her.  She lost her Senate seat after 12 years because she was a moderate Democrat who did not embrace the labor union platform.  The entire theme of her presentation was that this time our President needs to lead our country through these current fiscal challenges and that Congress needs to reach across the aisle to reach a compromise to avoid that fiscal cliff.  Her prediction is that both will happen.

Hurricane Sandy

I mentioned Hurricane Sandy in an earlier blog this week and noted that I would comment.  Last night, I had the opportunity to speak with a physician who has a home in New Jersey about his experience.  He said that it was truly like a war zone along with all of the hardship that such an experience would bring; fortunately the death toll was low, but it could have been far worse.  He said that he was amazed at the level of preparation that existed at Home Depot, for example.  Our government, not so much.  Home Depot took their resources and products from across the nation and completely overloaded the East Coast in advance of the storm.  He said that he was amazed as to their level of preparation. 

As for government, they mobilized around 48 hours after the hurricane hit.  There was chaos, confusion, shortages of everything, no power, no food, no water, no gasoline, houses flooded or destroyed......it was sheer bedlam.   I read of FEMA and the Red Cross being ill prepared initially; didn't they learn anything from Katrina?  At WMHS, we work very hard to learn from others, as well as ourselves, after crises and disasters.  We strive to make sure that we take the Home Depot approach rather than the approach of government.

I am thankful that life is beginning to be restored to somewhat normalcy in the NJ / NY area and hope that after this disaster, our government will "go to school" on the experience.

What Obamacare Means for Business

As I have blogged before, there a many positives with the Affordable Care Act (Obamacare); however, there are also negatives.  One glaring weakness is the minimum cost of a health benefit package as projected by the Congressional Budget Office.  The cost of the benefit package will be $5000 for an individual and $12,500 for a family. That translates into an additional $2.28 an hour for full-time employees with individual coverage and an additional $5.89 an hour for family coverage.  Adding the cash minimum wage to the family coverage benefit, the new minimum wage for employers becomes $13.14 per hour.  Many employers can't afford the added cost of health insurance in this economy and that is why you hear that employers will reduce staff, reduce employee hours, raise prices or force employees into a health exchange.  Low and moderate wage earners would receive a generous subsidy from the government by going into an exchange, but higher income employees get no subsidy.  This would force low income workers to work in companies that don't provide health insurance with an expectation for higher wages.  The higher income worker will work for companies that provide health insurance.  This will be an unbelievable burden on the tax payer with millions of employees taking advantage of the government subsidized coverage.  It will be interesting to watch.  If companies ignore what these employees prefer, then they could go out of business.  Stay tuned.

Meeting with the President

I read in the Wall Street Journal this a.m. that President Obama has invited twelve CEOs to meet with him at the White House to discuss a variety of critical issues facing our nation.  Even though my invitation must be delayed somewhere in the delivery process, I gave some thought to what I would discuss with the President given the opportunity.  First, pull out all stops to get the economy back on track.  Be a leader by working with Congress to an end that addresses our out-of-control debt.  Make the hard decisions that will return us to prosperity.  If you want to create jobs, then get to work on the Keystone pipeline and off-shore drilling.  Not only will both create jobs but they will diminish our dependence on foreign oil.  Be proud of our country and talk about our greatness to world leaders so they want to invest in America.  Recognize that you are held to a higher standard and bring the much promised transparency that you committed to during the first campaign for the Presidency.

Now, specific to health care: work to align incentives among providers (hospitals and physicians); you can't have one set of providers paid on volume and the other on value.  Address tort reform on a federal level.  You are putting providers in a precarious position by reducing admissions and re-admissions as well as reducing the amount of tests being ordered, yet leaving providers vulnerable to needless lawsuits and tort reform to the individual states to enact.  Lastly, recognize that cuts to providers will not reform health care; there needs to be a focus on prevention and wellness like never before along with an industry-wide focus on quality and cost.

Even if I am not in attendance tomorrow, I hope that such a meeting will get us back on track as a nation.

A Lot Can Happen in Less Than a Week

We re-elected a President last week, Hurricane Sandy clean up continues, a respected General resigns in scandal, the deep division of our country and our government raised its ugly head immediately following the election and the call for tax increases and no compromise started early on Wednesday AM.  First the re-election, not my candidate, but still my President.  I don't think that the Senate Democrats got the mandate from the American people that they claim they have.  The election map of America reflects urban vs. pretty much the rest of the country.   The continued division isn't good for anyone; I just hope that as President Obama assesses his next term, he realizes that he must reach a compromise with Congress on the economy or we are destined to be left in a financial spiral with little chance for recovery.  Also, you may try to tax your way out this mess, but it will take more than that.  A comprehensive plan is needed with true leadership from the President, Senate President Reid and Speaker Boehner. 

Now onto General Petraeus. Wow, knock me over with a feather; I didn't see that one coming.  This guy has walked on water through his service to our country as a military leader and then as CIA Director.  You would think that he would have known better, but obviously he didn't.  The affair had been going on for some time and he ended it a few months ago.  Apparently, the only reason the affair came out was that the spawned lover was under the impression that another woman had taken her man away.  It was the other woman who reported the threatening emails to the FBI.  Quite honestly, it's pretty scary that someone could that easily influence the director of the CIA and no one knows about it within our government.  Reports are that the general and his mistress weren't even that discreet.  Really disconcerting.  I will blog about my thoughts on Hurricane Sandy tomorrow.  It's good to be back blogging after a brief hiatus.

Voting

Today is Election Day and I encourage everyone to get out and vote.  I had the opportunity to vote last week as a part of early voting in Maryland.  I was surprised at how crowded it was when I arrived.  The poll workers said that it was like Election Day on that particular day since it was so crowded.  I love the convenience of early voting since voting on Election Day had its challenges for me.  I try to be at the office by 7 AM each morning, but since the polls open on Election Day at 7 AM, I am delayed in getting to the office.  I certainly don't begrudge anyone's right to vote; but on Election Day when I would arrive at the polling place to vote, there was always a very long line by 7 AM.  Many of the retired folks were there bright and early to exercise their right to vote.  I wished that they would stay home and have another cup of coffee until about 8 AM. 

For early voting this year, I was one of 500,000 early voters in Maryland last week.  When I arrived for early voting, I knew the gentleman checking in voters.  He said even though he knew me, he still had to ask my name, address and birthdate.  I gave it to him, but said that he should be asking for my driver's license or some other form of identification.  He laughed and said that I wasn't the first to suggest it.  So why don't we have such a requirement, as is the case with the new voter ID law in Virginia.  You have to show ID for virtually everything these days and having a voter ID requirement is Maryland simply makes sense.  If it's because there is limited or no ability for the poor to afford or obtain identification, give it to them for free and have it available in locations beyond MVA, such as the post office, health dept., police dept., etc.  In this day and age, fraud is rampant throughout life so why not put as many safeguards in place as possible?

I will not be blogging again until Monday; have a great weekend, but first get out and vote.

Tour of a Lifetime

This morning, the WMHS Foundation culminated a year's worth of mission tours into a breakfast recognizing our Trauma Program.  Throughout the year, each mission tour consisted of a tour of our Trauma Center and a 15-minute video that captured the horrific accident and life and death struggle of Ashton Zegles.  At our culminating breakfast, a group of around 100 heard of four other grateful trauma patients whose lives were saved by the staff at WMHS.  The breakfast ended with a visit and brief remarks from Ashton and her mother, Michelle.  Ashton lost a leg as a result of the accident, but she has fully recovered from the accident and continues to lead a wonderful life.  Ashton and her mother continue to be extremely grateful to WMHS for saving Ashton's life, as was the case of the other four grateful patients.  I continue to be in awe of our staff that creates such stories each day at WMHS through their actions in life and death situations.  We are so fortunate to have a committed and dedicated staff that goes beyond the routine care of the patient.  This staff clearly has a calling since what they do each day is so much more than just a job. 

End-of-Life Spending on Health Care

Yesterday, I blogged about the rationing of health care. It is a very difficult topic to discuss as no one wants to withhold anything from anyone especially related to one's health and well being.  However, what I find interesting is that the fear of rationing could be more of an "American thing," if you will.  My reason for thinking that way is depicted in the graph below.  It shows US spending for health care by age group compared to other countries.  On the graph, you will see that beginning at age 58 spending in the US begins a rapid ascent and reflects much higher spending per capita for older adults in the US compared to other industrialized nations.  In the US, the federal government spends $1.7 trillion per year on health care and 44 cents of every dollar spent is borrowed due to our debt situation; obviously unsustainable.  Countries like Spain, Great Britain, Germany and Sweden have figured out how to keep spending to a reasonable level for their citizens; possibly, we could learn how they have accomplished the ability to care for their citizens no matter what their age.  Have a good weekend after a very challenging week for many of us.