Dear Friends and Colleagues;
A recent article published in Health Affairs (http://content.healthaffairs.org/cgi/content/full/hlthaff.25.w457/DC1) focuses on the US Healthcare System performance as it compares to other nations in the world.
I can imagine that some of you may not like the findings of this study, but we need and we should proactively address these issue and not wait for others (i.e. the government) to resolve those problems:
According to the authors the United States has many of the world’s best-equipped hospitals and most highly specialized physicians. At 16 percent of gross domestic product (GDP), U.S. health spending is double the median of industrialized countries and since 2000 has been growing more rapidly than before.Yet the United States is the only major industrialized country that fails to guarantee universal health insurance; coverage in this country is deteriorating, leaving millions without affordable access to care.The U.S. health system also is not the best on quality of care, nor is it a leader in health information technology (IT).
To delineate the status of U.S. health care and opportunities to improve, the authors have developed a national scorecard spanning health outcomes, quality, access, efficiency, and equity in one report.
Thus, the scorecard, which was designed to assess and monitor all key dimensions of performance in relationship to benchmarks and over time, provides a unique whole-system view. Benchmarks and targets for improvement are based primarily on levels achieved internationally or within the United States.
Study Methods:
With guidance from the Commonwealth Fund Commission on a High Performance Health System and input from leading experts, the scorecard includes key indicators drawn from efforts of public, professional, and other national entities plus new analyzes. Criteria for indicator selection focused on sentinel or whole-system measures that capture key areas where improvement could make a major difference for the public, where information is available from international or national databases, and where the potential exists for time-trend analyzes. In total, the scorecard includes thirty-seven scored indicators, many of which are composites. The indicator set includes thirteen from new data analyzes and composites developed for the scorecard; the remainder represent an array from past research and ongoing efforts to track quality performance.
Some of the highlights of the report are as follows:
OUTCOME MEASURES:
"Long, Healthy and Productive Lives"
An indicator of mortality from conditions amenable to health care, widely used in Europe, is deaths before age seventy-five from conditions that are at least partially preventable or modifiable with timely and effective health care. The United States ranked fifteenth out of nineteen countries on this indicator as of 1998, with a death rate more than 40 percent higher than the benchmark, which is the average of the three best countries (France, Japan, and Spain).
The United States ranked last on infant mortality out of twenty-three industrialized countries as of 2002, with rates more than double the average of the three leading countries (Iceland, Japan, and Finland). The United States tied for last with Portugal, Ireland, Denmark, and the Czech Republic on healthy life expectancy at age sixty. The U.S. ranking reflects shorter life expectancy and more years of life with poor health and disability.
Within the United States, there is wide variation across states on the percentage of working-age adults with health-related limits on their ability to work or do other activities and in the percentage of children missing eleven or more days from school because of illness or injury.
Quality of Care:
High-quality care means care that is “right” (effective), well-coordinated, safe, patient-centered, and timely. On multiple quality indicators there are substantial spreads between the top and bottom groups of hospitals, health plans, or states
Based on patients’ reports, just about half of adults receive all recommended clinical screening tests and preventive care according to U.S. national guidelines.Only half of adults and 59 percent of children needing mental health care receive treatment. Rates are only 15 percent better for high-income adults. In general, the scorecard results confirm those of a medical-record-review study that found low rates of receipt of recommended care for adults.
For children, receipt of basic vaccines and annual preventive medical and dental care varies greatly across states.
As a result, national averages are well below the benchmark top 10 percent of states. National average rates of chronic disease control—using diabetes and hypertension as key indicators—also fall well below benchmark rates achieved by the top decile of health plans. Even within managed care plans, there is a wide spread in performance.
Hospitals vary in their provision of care according to basic clinical guidelines for heart attacks, congestive heart failure (CHF), and pneumonia. Although top-performing hospitals reached 100 percent adherence, hospitals delivered recommended care only 84 percent of the time on a composite measure of ten clinical processes that are reported to Medicare in exchange for full payment updates.
Across the United States, patients discharged from the hospital with CHF receive written discharge instructions only 50 percent of the time, on average, and there is an eighty-percentage-point spread between the top and bottom 10 percent of hospitals and a forty-percentage-point spread between the top and bottom 10 percent of states (64 percent versus 26 percent, data not shown). Patients hospitalized for mental health conditions often do not receive follow-up care within thirty days of discharge. On both CHF and mental illness indicators, there is a gap of twenty to thirty percentage points between national averages and rates achieved by the top group of hospitals or health plans. These shortcomings put patients at risk for complications and readmissions and raise the cost of care.
Visits to doctors for adverse drug events vary greatly across regions and have increased in the past five years. The percentage of elderly people prescribed one of thirty-three drugs listed as inappropriate has edged up since 2000, as has the percentage of children prescribed antibiotics for sore throats since 1998.
Among nursing home residents, inadequate care can result in pressure sores with risks of serious complications.
It would take a 33 percent reduction in national pressure sore rates to reach the average level achieved by the top five states.
Hospital-standardized mortality ratios provide an overall indicator of hospital safety and quality used internationally and in the United States to target improvement. Based on 2000–2002 mortality rates for Medicare beneficiaries, there is a thirty-three-percentage-point spread between the risk-adjusted mortality ratios achieved in the best 10 percent of hospitals (lowest rate) and the bottom 10 percent. If hospitals with observed mortality rates that are higher than expected brought deaths down to the levels that were expected given their patient mix, the improvement would translate into an estimated 17,000–21,000 fewer deaths per year. Reducing mortality rates to the level achieved by the top-performing group of hospitals (lowest 10 percent) would more than triple the number of lives saved.
Studies repeatedly find that the single most important determinant of whether patients obtain essential health care is having health insurance.
Affordability of Care
With insurance premiums rising at higher rates than wages and consumer cost sharing up sharply, the affordability of insurance and care is of increasing concern to middle- and low-income families and employers.
The scorecard includes two indicators for universal participation: adequate insurance and receipt of needed care. The insurance indicator tracks the percentage of adults who are adequately insured all year. Inadequate protection or being underinsured is defined as having expenses that exceed 10 percent of family income (5 percent for those with incomes below 200 percent of the federal poverty level) or being exposed to deductibles that alone constitute 5 percent of income. As of 2003, sixteen million U.S. adults (ages 19–64) were underinsured, and sixty-one million adults (35 percent) were either uninsured or underinsured. In 2004, 40 percent of U.S. adults reported that they went without care because of costs during the year, a rate four times higher than in the United Kingdom, the benchmark country.
Only 58 percent of the nonelderly population lives in a state where employer insurance premiums average less than 15 percent of this population’s median household income. One-third of nonelderly adults report having problems with medical bills, collection agencies, or medical debt. High out-of-pocket and premium costs compared to income affect 17 percent of all nonelderly families. Time trends on all three indicators have been moving toward less affordability.
Efficiency:
An efficient care system seeks to maximize the quality of care and outcomes for the resources committed to health care, and it focuses on strategies that produce greater net value over time. The scorecard includes five clusters of efficiency indicators: evidence of overuse, inappropriate care, duplication, or waste; inefficient use of resources associated with poor access; regional variations in quality and costs; percentage of health expenditures on insurance administrative costs; and lack of information systems that foster efficiency. The findings point to opportunities to gain net value, including saving lives and reducing costs if the nation could move toward rates achieved by the highest-performing regions
U.S. patients often report that records or test results were not available at the time of their appointment and that doctors unnecessarily repeated tests. In a six-nation survey, U.S. rates are two to three times the lowest-rate benchmark countries on both indicators.
Within the United States, the NCQA has begun tracking potential overuse or inappropriate care by expanding Health Plan Employer Data and Information Set (HEDIS) measures to include ordering of imaging tests for patients with lower back pain with no apparent risk factors. Among both private and Medicaid plans, the average rates of potentially inappropriate testing are 50 percent higher than are those for the lowest 10 percent of health plans.
Lack of availability of physicians when a patient is sick or in need of after-hours care can result in a visit to a hospital ER. Based on a cross-national survey in six nations asking patients about ER use for conditions that could have been seen by a regular doctor if available, it would require nearly an 80 percent reduction in U.S. rates to reach rates achieved by Germany and New Zealand, the benchmark countries. Within the United States, ER use rates for conditions that could have been cared for by regular doctors were significantly higher for uninsured, low-income, and minority patients.
Equity:
National policy statements, including the Healthy People 2010 targets, have made reducing and eliminating disparities in U.S. health care a top priority. The scorecard documents major inequities in health, quality, access, and efficiency dimensions. Disparities are widest in the paired contrasts by income or insurance, with an average 34 percent gap between uninsured and insured populations and a 38 percent gap between low-income and high-income populations. On multiple indicators, it would require a 50 percent or greater improvement in rates among the low-income or uninsured to equal the experience of high-income or insured groups. Living in low-income communities also is associated with disparities. Cancer statistics demonstrate systematically lower five-year survival for whites, blacks, and Hispanics in high-poverty geographic areas.
Perspective:
The overall picture that emerges from the scorecard is one of missed opportunities and room for improvement. Despite high expenditures, the United States lags behind other countries on indicators of mortality and healthy life expectancy. Within the United States, there is often a substantial spread between the top and bottom groups of states, hospitals, or health plans as well as wide gaps between the national average and top rates. As a result, the U.S. performance relative to benchmarks averages near 50 for efficiency to 70 for healthy lives, quality, access, and equity, for an overall average score of 66 across the main domains of performance On multiple indicators, the United States would need to improve its performance by 50 percent or more to reach benchmark countries, regions, states, hospitals, health plans, or targets.
Policies are needed that address the interaction of access, quality, and cost and take a coherent, whole-system view rather than a fragmented approach to change. Universal coverage and participation are essential to improving health care quality and cost performance. High and rising rates of the population that is under- and uninsured destabilize the delivery system, fuel inefficient use of resources, and put families and the nation at risk of losing ground on past gains in health and workforce productivity.
Lack of access to primary care, poor quality in hospitals and nursing homes or during transitions, and inadequate information systems contribute to duplicate efforts, inefficient use of specialized care, and higher rates of hospital admission and readmission, which raise the costs of care and lead to poorer outcomes.
There is evidence that quality and efficiency can be improved together. Savings can be generated from more efficient use of costly resources, producing the same or better quality at lower resource cost. The challenge is finding systematic ways to achieve net gains and rechannel the savings into investments to improve coverage and the capacity to innovate. The critical importance of improving coordination of care emerges across multiple indicators. Policies that facilitate and promote more-connected care, linking medical care providers and information in more integrated care systems, will be essential for productivity, efficiency, and quality gains.
U.S. Health System Performance:
A National Scorecard
The United States would have to improve its performance
on key indicators by 50 percent or more to reach benchmark rates.
by Cathy Schoen, Karen Davis, Sabrina K. H. How,
and Stephen C. Schoenbaum
ABSTRACT:
This paper presents the findings of a new scorecard designed to assess and monitor multiple domains of U.S. health system performance. The scorecard uses national and international data to identify performance benchmarks and calculates simple ratio scores comparing U.S averages to benchmarks. Average ratio scores range from 51 to 71 across domains of health outcomes, quality, access, equity, and efficiency. The overall picture that emerges from the scorecard is one of missed opportunities and room for improvement. The findings underscore the importance of policies that take a coherent, whole-system approach to change and address the interaction of access, quality, and cost. [Health Affairs 25 (2006): w457–w475; 10.1377/hlthaff.25.w457]
Sunday, September 24, 2006
Medicare Again
Dear Friends and Colleagues:
Unfortunately, the Medicare reimbursement cuts are looming on the horizon AGAIN, but this time we have a hard time to stop the proposed cuts of 5.1%.
Already "doctors friendly" Republicans admit privately that the AMA campaign seeking to prevent the Medicare cuts amounts to piling during a difficult election season when Republicans are trying to hold onto control of Congress. According to media reports lawmakers are unlikely to raise Medicare payments to physicians since financing possibilities rankle “whoever’s ox is gored,” a Republican aide says.
According to Medicare officials the volume and intensity of medical care will push up costs for physician-related services by 5% next year.Without the planned reimbursement cuts of 40% until 2015, Part B spending would increase by a total of $2.8 billion in 2007. It is of interest to note that the reversal of this years planned cut of 5.1% would increase the Medicare premiums by only $1.50!
Many of our patients are not aware how those intended Medicare cuts are going to affect access to patient care. But according to an AMA survey once told about it, 86% are concerned about access to physician care in Medicare. When seniors —who tend to be a big voting bloc in midterm elections— are asked, 82% say they are concerned about access to physicians.
What are the solutions:
1) Inform your patients how those cuts will adversely affect their access to care
2) Support OUR AMA in the effort to stop the cuts. See the AMA web site for more information.
3) Consider opting-out of Medicare, which may be the a viable solution to safe your practice (I have done so 7 years ago)
What you should NOT DO: To ignore the looming crisis and to increase your patient load to "make up" for lost income. This is a flawed formula, because your overhead will increase exponentially leaving you with less profit or worse with a loss.
I also want to wish all of my fellow Jewish colleagues a Happy New Year, Shana Tova and Chatima Tova. For my Muslim brothers and Sisters I wish them a heartfelt joyous and blessed Ramadan,Ramdan- ul - mubarak.
Yours
Bernd
Most Medicare Part B Premiums to Rise Slightly
By JANE ZHANG
September 13, 2006; Page D4
WASHINGTON -- Most seniors will see a smaller-than-expected increase in their monthly Medicare premiums for physician and outpatient care next year, but for the first time in the program's history, wealthier beneficiaries will pay premiums based on their incomes.
The federal Centers for Medicare and Medicaid Services said most seniors will pay a $93.50 monthly premium for coverage under Medicare's Part B, $5 more than this year, and lower than the double-digit increase earlier projected, to more than $98.
Meanwhile, wealthier beneficiaries will pay premiums, ranging as high as $162 every month for individuals with annual incomes of more than $200,000 down to $106 a month for those earning more than $80,000. The higher premiums for next year will be based on incomes declared in the 2005 tax year and will be adjusted for inflation.
The change, based on the 2003 Medicare law, will affect about 1.5 million Americans and save the program $20.8 billion in the next 10 years, officials said.
Part B premiums generally cover 25% of Medicare's costs, with the government footing the rest. But as a result of the change, the subsidy for higher-income beneficiaries is expected to decline to as low as 20% from 75%.
Some analysts worry that the change will transform the Medicare health-insurance program into a welfare program for lower-income seniors. But CMS chief Mark McClellan said that only about 9,000 of the higher-income enrollees are expected to drop out next year and 30,000 by 2010, when the change is fully implemented. Even the wealthiest beneficiary will receive a good insurance package, he said, $4,363 for Part B benefits, or physician and outpatient care, for a $1,945 annual premium.
The increase in the standard Medicare premiums, by 5.6%, to $93.50, is lower than expected, largely because physicians are filing claims faster and getting paid more quickly, the government said. Part B premiums saw double-digit growth since 2001, when the premium was $50 every month.
Still, Medicare spending keeps rising. Costs for outpatient hospital care, while only 13% of total Part B spending, accounted for a third of premium increase in 2007, Medicare officials said. Those costs are expected to grow by 11.6% per capita in 2007, while volume and intensity of care will push up costs for physician-related services by 5% next year.
The premiums announced yesterday included calculations of a 5% cut in physician payments for 2007, but Congress has reversed such cuts four years in a row. And if lawmakers do it again this year, as urged by the American Medical Association, this would require an additional $1.50 increase in 2007 premiums, Dr. McClellan said.
Without the cut, Part B spending would increase by a total of $2.8 billion in 2007. Based on federal law, Medicare will reduce physician reimbursement by 40% in the next nine years.
If the cuts go through, the AMA said, nearly half of physicians surveyed will stop taking new Medicare patients, just as baby boomers are set to start turning 65 in five years. The AMA will unveil an advertising campaign today to urge Congress to reverse the cuts before the fall recess. Physicians will come to Washington to make a "house call" on lawmakers, the group announced.
But Congress is unlikely to act before November, some congressional aides say.
Unfortunately, the Medicare reimbursement cuts are looming on the horizon AGAIN, but this time we have a hard time to stop the proposed cuts of 5.1%.
Already "doctors friendly" Republicans admit privately that the AMA campaign seeking to prevent the Medicare cuts amounts to piling during a difficult election season when Republicans are trying to hold onto control of Congress. According to media reports lawmakers are unlikely to raise Medicare payments to physicians since financing possibilities rankle “whoever’s ox is gored,” a Republican aide says.
According to Medicare officials the volume and intensity of medical care will push up costs for physician-related services by 5% next year.Without the planned reimbursement cuts of 40% until 2015, Part B spending would increase by a total of $2.8 billion in 2007. It is of interest to note that the reversal of this years planned cut of 5.1% would increase the Medicare premiums by only $1.50!
Many of our patients are not aware how those intended Medicare cuts are going to affect access to patient care. But according to an AMA survey once told about it, 86% are concerned about access to physician care in Medicare. When seniors —who tend to be a big voting bloc in midterm elections— are asked, 82% say they are concerned about access to physicians.
What are the solutions:
1) Inform your patients how those cuts will adversely affect their access to care
2) Support OUR AMA in the effort to stop the cuts. See the AMA web site for more information.
3) Consider opting-out of Medicare, which may be the a viable solution to safe your practice (I have done so 7 years ago)
What you should NOT DO: To ignore the looming crisis and to increase your patient load to "make up" for lost income. This is a flawed formula, because your overhead will increase exponentially leaving you with less profit or worse with a loss.
I also want to wish all of my fellow Jewish colleagues a Happy New Year, Shana Tova and Chatima Tova. For my Muslim brothers and Sisters I wish them a heartfelt joyous and blessed Ramadan,Ramdan- ul - mubarak.
Yours
Bernd
Most Medicare Part B Premiums to Rise Slightly
By JANE ZHANG
September 13, 2006; Page D4
WASHINGTON -- Most seniors will see a smaller-than-expected increase in their monthly Medicare premiums for physician and outpatient care next year, but for the first time in the program's history, wealthier beneficiaries will pay premiums based on their incomes.
The federal Centers for Medicare and Medicaid Services said most seniors will pay a $93.50 monthly premium for coverage under Medicare's Part B, $5 more than this year, and lower than the double-digit increase earlier projected, to more than $98.
Meanwhile, wealthier beneficiaries will pay premiums, ranging as high as $162 every month for individuals with annual incomes of more than $200,000 down to $106 a month for those earning more than $80,000. The higher premiums for next year will be based on incomes declared in the 2005 tax year and will be adjusted for inflation.
The change, based on the 2003 Medicare law, will affect about 1.5 million Americans and save the program $20.8 billion in the next 10 years, officials said.
Part B premiums generally cover 25% of Medicare's costs, with the government footing the rest. But as a result of the change, the subsidy for higher-income beneficiaries is expected to decline to as low as 20% from 75%.
Some analysts worry that the change will transform the Medicare health-insurance program into a welfare program for lower-income seniors. But CMS chief Mark McClellan said that only about 9,000 of the higher-income enrollees are expected to drop out next year and 30,000 by 2010, when the change is fully implemented. Even the wealthiest beneficiary will receive a good insurance package, he said, $4,363 for Part B benefits, or physician and outpatient care, for a $1,945 annual premium.
The increase in the standard Medicare premiums, by 5.6%, to $93.50, is lower than expected, largely because physicians are filing claims faster and getting paid more quickly, the government said. Part B premiums saw double-digit growth since 2001, when the premium was $50 every month.
Still, Medicare spending keeps rising. Costs for outpatient hospital care, while only 13% of total Part B spending, accounted for a third of premium increase in 2007, Medicare officials said. Those costs are expected to grow by 11.6% per capita in 2007, while volume and intensity of care will push up costs for physician-related services by 5% next year.
The premiums announced yesterday included calculations of a 5% cut in physician payments for 2007, but Congress has reversed such cuts four years in a row. And if lawmakers do it again this year, as urged by the American Medical Association, this would require an additional $1.50 increase in 2007 premiums, Dr. McClellan said.
Without the cut, Part B spending would increase by a total of $2.8 billion in 2007. Based on federal law, Medicare will reduce physician reimbursement by 40% in the next nine years.
If the cuts go through, the AMA said, nearly half of physicians surveyed will stop taking new Medicare patients, just as baby boomers are set to start turning 65 in five years. The AMA will unveil an advertising campaign today to urge Congress to reverse the cuts before the fall recess. Physicians will come to Washington to make a "house call" on lawmakers, the group announced.
But Congress is unlikely to act before November, some congressional aides say.
Thursday, August 24, 2006
Medicare - Is There a Doctor In The House?
Dear Friends and Colleagues:
Attached an interesting article from the Wall Street Journal (08/21/06) describing the increasing difficulties that seniors face finding a doctor who either still accepts new Medicare patients or is still in practice.
As predicate the diminishing Medicare reimbursement is adversely affecting the quality of care and access to medical care.
It can only get worse unless the SGR is not changed.
See you in Orlando.
Bernd
Is There a Doctor in the House?
It's becoming tougher to find -- and keep -- the medical providers you need in later life, particularly in retirement hot spots. Here are some strategies to get the care you're looking for.
By KELLY GREENE
August 21, 2006; Page R1
Jeane McDade, a retired legal assistant in Santa Cruz, Calif., feels like her doctors are going through a "revolving door."
Since January, her internist and neurologist have left town, and two other specialists who treated her have retired. Three primary-care doctors turned down her request for an appointment, saying they weren't taking new Medicare patients.
Ms. McDade, 83 years old, finally begged an appointment with an internist who is married to one of her other doctors. As far as finding a neurologist, "I'll just have to take whoever I can get," she says.
It's a predicament that's marring retirement for older Americans in pockets dotting the country, particularly temperate, picturesque spots like Santa Cruz that are a magnet for retirees. Finding and keeping a doctor for some patients is becoming a trial, and health-care executives and patient advocates alike are concerned that the situation will only get worse as the number of retirees grows dramatically in coming years.
"Come 2011, when the baby boomers hit 'Golden Pond,' we're just not going to have enough doctors," says David Reuben, president of the American Geriatrics Society and geriatrics chief at the David Geffen School of Medicine at the University of California, Los Angeles.
Money, of course, is part of the problem. Some doctors are leaving towns like Santa Cruz because of the relatively low payments they get from Medicare, the federal health-insurance program for people 65 and older. The government reimburses doctors in Santa Cruz County using the same system that's been in place since long before the Northern California real-estate boom. That means doctors make 15% to 20% less for seeing Medicare patients there than they do in neighboring Santa Clara County.
But even in places where Medicare pays relatively well, other factors are making it tough for older patients to get face time with doctors. Demand for medical services is increasing, a reflection of advances in technology used to diagnose and treat medical problems, along with extended life spans and the resulting increase in the number of chronically ill patients. What's more, doctors are less likely than before to set up their own practices and stay put. Instead, they are forming ever-larger group practices or are going to work for hospital systems that are adding staff -- all to better negotiate with insurers. That mobility can exacerbate local physician shortages. Meanwhile, among the new wave of retirees are many doctors, who aren't necessarily being replaced in the same places or specialties.
Even when doctors can be found, patients may have to wait weeks or months for an appointment. And many patients may feel that their doctors don't set aside enough time for consultations, either during office visits or when questions arise.
So, how can you get the medical care you need in the face of predictions of worsening doctor shortages? We asked health-care experts, geriatric-care managers and patients themselves to pinpoint strategies that you can pursue. Here's their advice:
LOCATION, LOCATION, LOCATION
If you're planning to move in retirement, you're probably already thinking about such considerations as climate, housing costs and tax rates. Now, there's another question you should add to your list: How many of the well-regarded doctors where you want to live are accepting new Medicare patients?
"If I were the son of an elderly person moving to a retirement community," says Dr. Reuben, the Los Angeles geriatrician, "I would want to know more about what's available in terms of medical resources. You have to find out how good a payer Medicare is. There are some states where they don't want any Medicare business, it's such a poor payer."
Unfortunately -- beyond the tedium of checking with individual doctors -- there's no simple way to find out how Medicare payments in a particular locale are affecting the availability of services.
Overall, there seem to be enough doctors to go around. In fact, 73% of doctors nationwide reported accepting all new Medicare patients in 2004 and 2005; only 3% closed their practices to the group, according to a January report by the Center for Studying Health System Change in Washington.
And a July report from the Government Accountability Office found no more than 7% of Medicare patients reported problems finding a doctor from 2000 through 2004. Still, the same report says the proportion of those reporting major difficulties varied by as much as 12 percentage points from state to state.
Retirees and health-care experts we interviewed have seen doctors close their doors in pockets of states ranging from California and Idaho to Florida and Virginia -- places that are popular with retirees and where government payments to physicians haven't necessarily kept up with rising living costs.
If you find that you have choices among doctors who are accepting new patients, you may want to weigh how long each doctor has been in practice. That's because doctors who are more established in a practice are less likely to move away, health-care experts say, especially doctors who own the buildings they practice in and do their own hiring.
Dean Kashino, a family practitioner in Santa Cruz, suggests that if you're planning to relocate in retirement, you do so before you turn 65 and qualify for Medicare. "That way, you have a better chance of latching onto a physician" who will retain you as a patient after you become eligible for Medicare, he says.
THINK LIKE A SALESPERSON
In other words, don't take "no" for an answer -- and push doctors to acknowledge your request for help.
Ireta Metchik, a geriatric-care manager in Boston, says she has the most success getting patients appointments with coveted doctors, or rare spots in treatment facilities, by making personal connections and then arguing her case. For example, she recently was worried that a client with multiple physical and psychiatric issues "might die." Even though the patient had adequate financial resources, "I could not get him admitted to a good geriatric psychiatric hospital," she says.
After visiting her client at home, and finding him weak and depressed, Ms. Metchik called his primary-care doctor, clinical social worker, and the doctor's secretary "on a continual basis for two days" to enlist their help. Meanwhile, she checked out the patient's insurance so the primary-care doctor would know that the patient's hospital stay would be covered. Finally, the doctor "realized -- perhaps by sheer repetition -- the seriousness of it, and the connection I had to this man," and admitted him, she says.
Don't expect success every time you squawk. Robert Kane, a geriatrician and professor at the University of Minnesota School of Public Health in Minneapolis, organized an advocacy group called Professionals With Personal Experience in Chronic Care. The group comprises geriatricians, gerontologists and other health-care professionals who have struggled to help their own relatives get access to appropriate medical care.
"My epiphany came around 2000 when my mother had a stroke," Dr. Kane says. "I'm a geriatrician and I have written policy books, but basically I spent three frustrating years with my sister trying to organize care for my mother. If somebody who knows as much as I do and knows as many people as I do couldn't get the system to work, what chance does anyone have?"
His advice for advocating for yourself or an older family member: "First, recognize that it may take a while to find a doctor -- and it may take even longer to find a doctor who you want. Second, you need to be proactive to make the system work. Keep a very clear record of your medications. Ask a physician when he's ordering a drug if he's aware of the other drugs you're on." In other words, "you need to become your own advocate. If you can't do that, that's where your family comes in."
HIRE A LOBBYIST
Many people don't realize there are professionals they can hire to help older patients get the care they need.
Geriatric-care managers, who can help assess health-care needs, arrange for medical treatment and schedule home services, can be located through an online directory at CareManager.org10, the site for the National Association of Professional Geriatric Care Managers. The site also lists questions to ask when hiring a geriatric-care manager -- an important step, since most states don't license managers. The cost of the services typically ranges from $85 to $200 an hour.
Check out your employee benefits, as well -- and your children's. Some big companies, such as Ford Motor Co., provide their employees' elderly relatives with a free or reduced-cost visit by a geriatric-care manager. The manager assesses the subject's health, writes a report detailing the findings, and develops a care plan. A few organizations, including Fannie Mae, the Washington-based mortgage agency, have hired their own elder-care case managers to help workers.
BEYOND THE DOCTOR'S OFFICE
Healthy patients who are tired of fighting for a spot with an internist and are interested primarily in prevention may be able to get the screenings they need for blood pressure, blood sugar, cholesterol and so forth through local health fairs, often held at shopping malls. Medical schools typically house clinics that can meet the same needs.
If you're looking for more continuity in your care than that, you could try seeing a nurse practitioner, particularly to help manage chronic conditions. (A nurse practitioner is a registered nurse with advanced training and education.) There's a national directory at NPClinics.com11.
For minor medical problems that can be handled over the phone, TelaDoc Medical Services Inc., a round-the-clock telephone consulting service based in Dallas, charges about $4 a month for membership and $35 for each consultation. Calls are toll-free. Information on the service can be found at TelaDoc.com12.
For the frailest patients, some doctors -- particularly geriatricians -- make house calls, partly because they can get paid more by Medicare than for office visits. In most cases, this is limited to dense metropolitan areas such as Washington and New York, but a few doctors in areas like Reno, Nev., and Southern California have made a go of it. The Web site for the American Academy of Home Care Physicians (AAHCP.org13) has a listing of such doctors.
BEFRIEND YOUR PHARMACIST
Another valuable resource outside the doctor's office is a pharmacist. If the one at your local drugstore doesn't offer enough help, you can hire a few hours of advice from a consulting pharmacist who specializes in drug interactions and in the ways that older adults react to medications.
Some pharmacists with that specialty take a test and get certified through the Commission for Certification in Geriatric Pharmacy in Alexandria, Va. There is a directory of certified geriatric pharmacists at the commission's Web site, CCGP.org14.
If you can't find a pharmacist near you or your parent who has taken the certification test, don't give up. Many pharmacists have a lot of experience counseling older customers about potential drug interactions and helping them sort things out when side effects surface.
The American Society of Consultant Pharmacists, based in Alexandria, Va., offers a directory of "senior care" pharmacists at SeniorCarePharmacist.com15.
'DISEASE MANAGEMENT' PROGRAMS
There are several resources to consider for patients with chronic diseases.
Fledgling programs designed to manage chronic illnesses as long-term diseases, rather than to battle them like short-term crises, are often buried within the bureaucracy of big hospital systems or insurance companies, and a lot of patients who could use them don't know they exist.
Also, some large employers and health plans hire "disease management" companies to counsel employees and members, mainly by phone. Older people still working, or retirees who still have health benefits through former employers, may have access to such programs, says Molly Mettler, senior vice president of Healthwise Inc., a supplier of online and printed health information based in Boise, Idaho.
If you have a choice between traditional Medicare insurance and a Medicare managed-care plan, you may want to consider the latter to get more counseling for special health needs, says Marc Hoffing, medical director of the Oasis Independent Physician Association in Palm Springs, Calif., which contracts with managed-care plans. For the sickest patients in the Medicare managed-care plans that Mr. Hoffing's association serves, case managers are available 24 hours a day.
FIND A SUPPORT GROUP
In Washington state, Colorado, Northern California and a few other pockets around the country, doctors who work with older people are experimenting with grouping those patients together for appointments, even if, in some cases, they suffer from different health problems.
Such visits have proved so popular at Group Health Cooperative in Seattle that the nonprofit health-care system has expanded its pilot project to 20 locations, says Martin Levine, Group Health's medical director for senior care. Patients in the groups use the emergency room less, a big cost saver, and have seen their health improve in other ways.
The group visits start with an icebreaker, then move into a 30-minute discussion about a topic the patients agreed on the previous month, such as how to manage your medications, what happens if you're traveling and get sick, how to monitor high blood pressure, how to manage vision and hearing loss, and so forth. Then the group takes a coffee break, during which the doctors check in with people individually. In the last 10 minutes, the group decides what to talk about the following month.
"The patients come in with a whole mix of problems -- diabetes, heart disease, lung disease, arthritis," says Dr. Levine. "Over time, they realize they don't need their one-on-one visits so much." The patients often benefit from hearing their doctors' advice reinforced by people their own age, he adds.
"One doctor saw someone with headaches that had no explanation for eight years," says Dr. Levine. The doctor "ran out of things to offer her and told her to go out there, stay active, go for a walk. At a group visit, one woman told her, 'I go for a walk every day. You should go for a walk.' The woman with the headaches said, 'That's a good idea,' and they traded phone numbers." The two became walking partners, and the headaches went away.
LEARN MORE ABOUT HEALTH
Take the time to learn about health basics like nutrition or what preventive tests are appropriate at what ages.
One basic tool: a self-help health-care manual, such as "Healthwise for Life," co-authored by Ms. Mettler of Healthwise Inc., or the "Merck Manual of Health and Aging." Forty percent of patients in one study in Southern California who were given a self-care book reported saving a trip to the doctor's office; 39% said they saved a trip to the emergency room.
You also should get copies of your medical records, either online or on paper, says Beverly Bernstein Joie, president of Elder Connections Inc., a geriatric-care-management company in suburban Philadelphia. You are entitled to your medical records by law.
For instance, when you see a specialist, such as a cardiologist, ask for a copy of your cardiogram and the report that goes to other physicians. That way, Ms. Joie says, if results and reports don't make it to other doctors, you have a backup copy and can still get the most out of future health-care appointments.
MOVE OFFSHORE
It might sound extreme, but some retirees are moving to Costa Rica, Mexico and other countries where health-care costs are appreciably lower and the quality of service, they say, is significantly better.
Several years ago, Robert Preston, an actuary in Sarasota, Fla., was frustrated with the lack of medical and custodial attention his father, the retired chief financial officer of a large pharmaceutical company, was receiving in Florida. Expenses totaled $10,000 a month for a room in a nursing home in Venice Beach, as well as personal attendants.
Mr. Preston started thinking about pursuing care for his father in another country. He settled on Costa Rica after a friend returned from a trip there, singing the praises of the country's medical services. Eventually, Mr. Preston's father settled in a private home in Costa Rica, with a house manager, chauffeur and three attendants -- all for about $3,000 a month. Instead of being confined to a nursing home, his father attended church every Sunday, took a large group to brunch afterward, went out to dinner several times a week -- and occasionally even went on a date. (Mr. Preston flew down to see his father once a month on a four-hour flight to San Jose, rather than a three-hour flight to Florida.)
Mr. Preston's father died in 2001. Since then, two of Mr. Preston's friends have moved family there.
"In Costa Rica, the medical system is excellent. My father's doctor there would call me up in Connecticut," Mr. Preston says. "I couldn't get doctors in Florida to return my phone calls."
Attached an interesting article from the Wall Street Journal (08/21/06) describing the increasing difficulties that seniors face finding a doctor who either still accepts new Medicare patients or is still in practice.
As predicate the diminishing Medicare reimbursement is adversely affecting the quality of care and access to medical care.
It can only get worse unless the SGR is not changed.
See you in Orlando.
Bernd
Is There a Doctor in the House?
It's becoming tougher to find -- and keep -- the medical providers you need in later life, particularly in retirement hot spots. Here are some strategies to get the care you're looking for.
By KELLY GREENE
August 21, 2006; Page R1
Jeane McDade, a retired legal assistant in Santa Cruz, Calif., feels like her doctors are going through a "revolving door."
Since January, her internist and neurologist have left town, and two other specialists who treated her have retired. Three primary-care doctors turned down her request for an appointment, saying they weren't taking new Medicare patients.
Ms. McDade, 83 years old, finally begged an appointment with an internist who is married to one of her other doctors. As far as finding a neurologist, "I'll just have to take whoever I can get," she says.
It's a predicament that's marring retirement for older Americans in pockets dotting the country, particularly temperate, picturesque spots like Santa Cruz that are a magnet for retirees. Finding and keeping a doctor for some patients is becoming a trial, and health-care executives and patient advocates alike are concerned that the situation will only get worse as the number of retirees grows dramatically in coming years.
"Come 2011, when the baby boomers hit 'Golden Pond,' we're just not going to have enough doctors," says David Reuben, president of the American Geriatrics Society and geriatrics chief at the David Geffen School of Medicine at the University of California, Los Angeles.
Money, of course, is part of the problem. Some doctors are leaving towns like Santa Cruz because of the relatively low payments they get from Medicare, the federal health-insurance program for people 65 and older. The government reimburses doctors in Santa Cruz County using the same system that's been in place since long before the Northern California real-estate boom. That means doctors make 15% to 20% less for seeing Medicare patients there than they do in neighboring Santa Clara County.
But even in places where Medicare pays relatively well, other factors are making it tough for older patients to get face time with doctors. Demand for medical services is increasing, a reflection of advances in technology used to diagnose and treat medical problems, along with extended life spans and the resulting increase in the number of chronically ill patients. What's more, doctors are less likely than before to set up their own practices and stay put. Instead, they are forming ever-larger group practices or are going to work for hospital systems that are adding staff -- all to better negotiate with insurers. That mobility can exacerbate local physician shortages. Meanwhile, among the new wave of retirees are many doctors, who aren't necessarily being replaced in the same places or specialties.
Even when doctors can be found, patients may have to wait weeks or months for an appointment. And many patients may feel that their doctors don't set aside enough time for consultations, either during office visits or when questions arise.
So, how can you get the medical care you need in the face of predictions of worsening doctor shortages? We asked health-care experts, geriatric-care managers and patients themselves to pinpoint strategies that you can pursue. Here's their advice:
LOCATION, LOCATION, LOCATION
If you're planning to move in retirement, you're probably already thinking about such considerations as climate, housing costs and tax rates. Now, there's another question you should add to your list: How many of the well-regarded doctors where you want to live are accepting new Medicare patients?
"If I were the son of an elderly person moving to a retirement community," says Dr. Reuben, the Los Angeles geriatrician, "I would want to know more about what's available in terms of medical resources. You have to find out how good a payer Medicare is. There are some states where they don't want any Medicare business, it's such a poor payer."
Unfortunately -- beyond the tedium of checking with individual doctors -- there's no simple way to find out how Medicare payments in a particular locale are affecting the availability of services.
Overall, there seem to be enough doctors to go around. In fact, 73% of doctors nationwide reported accepting all new Medicare patients in 2004 and 2005; only 3% closed their practices to the group, according to a January report by the Center for Studying Health System Change in Washington.
And a July report from the Government Accountability Office found no more than 7% of Medicare patients reported problems finding a doctor from 2000 through 2004. Still, the same report says the proportion of those reporting major difficulties varied by as much as 12 percentage points from state to state.
Retirees and health-care experts we interviewed have seen doctors close their doors in pockets of states ranging from California and Idaho to Florida and Virginia -- places that are popular with retirees and where government payments to physicians haven't necessarily kept up with rising living costs.
If you find that you have choices among doctors who are accepting new patients, you may want to weigh how long each doctor has been in practice. That's because doctors who are more established in a practice are less likely to move away, health-care experts say, especially doctors who own the buildings they practice in and do their own hiring.
Dean Kashino, a family practitioner in Santa Cruz, suggests that if you're planning to relocate in retirement, you do so before you turn 65 and qualify for Medicare. "That way, you have a better chance of latching onto a physician" who will retain you as a patient after you become eligible for Medicare, he says.
THINK LIKE A SALESPERSON
In other words, don't take "no" for an answer -- and push doctors to acknowledge your request for help.
Ireta Metchik, a geriatric-care manager in Boston, says she has the most success getting patients appointments with coveted doctors, or rare spots in treatment facilities, by making personal connections and then arguing her case. For example, she recently was worried that a client with multiple physical and psychiatric issues "might die." Even though the patient had adequate financial resources, "I could not get him admitted to a good geriatric psychiatric hospital," she says.
After visiting her client at home, and finding him weak and depressed, Ms. Metchik called his primary-care doctor, clinical social worker, and the doctor's secretary "on a continual basis for two days" to enlist their help. Meanwhile, she checked out the patient's insurance so the primary-care doctor would know that the patient's hospital stay would be covered. Finally, the doctor "realized -- perhaps by sheer repetition -- the seriousness of it, and the connection I had to this man," and admitted him, she says.
Don't expect success every time you squawk. Robert Kane, a geriatrician and professor at the University of Minnesota School of Public Health in Minneapolis, organized an advocacy group called Professionals With Personal Experience in Chronic Care. The group comprises geriatricians, gerontologists and other health-care professionals who have struggled to help their own relatives get access to appropriate medical care.
"My epiphany came around 2000 when my mother had a stroke," Dr. Kane says. "I'm a geriatrician and I have written policy books, but basically I spent three frustrating years with my sister trying to organize care for my mother. If somebody who knows as much as I do and knows as many people as I do couldn't get the system to work, what chance does anyone have?"
His advice for advocating for yourself or an older family member: "First, recognize that it may take a while to find a doctor -- and it may take even longer to find a doctor who you want. Second, you need to be proactive to make the system work. Keep a very clear record of your medications. Ask a physician when he's ordering a drug if he's aware of the other drugs you're on." In other words, "you need to become your own advocate. If you can't do that, that's where your family comes in."
HIRE A LOBBYIST
Many people don't realize there are professionals they can hire to help older patients get the care they need.
Geriatric-care managers, who can help assess health-care needs, arrange for medical treatment and schedule home services, can be located through an online directory at CareManager.org10, the site for the National Association of Professional Geriatric Care Managers. The site also lists questions to ask when hiring a geriatric-care manager -- an important step, since most states don't license managers. The cost of the services typically ranges from $85 to $200 an hour.
Check out your employee benefits, as well -- and your children's. Some big companies, such as Ford Motor Co., provide their employees' elderly relatives with a free or reduced-cost visit by a geriatric-care manager. The manager assesses the subject's health, writes a report detailing the findings, and develops a care plan. A few organizations, including Fannie Mae, the Washington-based mortgage agency, have hired their own elder-care case managers to help workers.
BEYOND THE DOCTOR'S OFFICE
Healthy patients who are tired of fighting for a spot with an internist and are interested primarily in prevention may be able to get the screenings they need for blood pressure, blood sugar, cholesterol and so forth through local health fairs, often held at shopping malls. Medical schools typically house clinics that can meet the same needs.
If you're looking for more continuity in your care than that, you could try seeing a nurse practitioner, particularly to help manage chronic conditions. (A nurse practitioner is a registered nurse with advanced training and education.) There's a national directory at NPClinics.com11.
For minor medical problems that can be handled over the phone, TelaDoc Medical Services Inc., a round-the-clock telephone consulting service based in Dallas, charges about $4 a month for membership and $35 for each consultation. Calls are toll-free. Information on the service can be found at TelaDoc.com12.
For the frailest patients, some doctors -- particularly geriatricians -- make house calls, partly because they can get paid more by Medicare than for office visits. In most cases, this is limited to dense metropolitan areas such as Washington and New York, but a few doctors in areas like Reno, Nev., and Southern California have made a go of it. The Web site for the American Academy of Home Care Physicians (AAHCP.org13) has a listing of such doctors.
BEFRIEND YOUR PHARMACIST
Another valuable resource outside the doctor's office is a pharmacist. If the one at your local drugstore doesn't offer enough help, you can hire a few hours of advice from a consulting pharmacist who specializes in drug interactions and in the ways that older adults react to medications.
Some pharmacists with that specialty take a test and get certified through the Commission for Certification in Geriatric Pharmacy in Alexandria, Va. There is a directory of certified geriatric pharmacists at the commission's Web site, CCGP.org14.
If you can't find a pharmacist near you or your parent who has taken the certification test, don't give up. Many pharmacists have a lot of experience counseling older customers about potential drug interactions and helping them sort things out when side effects surface.
The American Society of Consultant Pharmacists, based in Alexandria, Va., offers a directory of "senior care" pharmacists at SeniorCarePharmacist.com15.
'DISEASE MANAGEMENT' PROGRAMS
There are several resources to consider for patients with chronic diseases.
Fledgling programs designed to manage chronic illnesses as long-term diseases, rather than to battle them like short-term crises, are often buried within the bureaucracy of big hospital systems or insurance companies, and a lot of patients who could use them don't know they exist.
Also, some large employers and health plans hire "disease management" companies to counsel employees and members, mainly by phone. Older people still working, or retirees who still have health benefits through former employers, may have access to such programs, says Molly Mettler, senior vice president of Healthwise Inc., a supplier of online and printed health information based in Boise, Idaho.
If you have a choice between traditional Medicare insurance and a Medicare managed-care plan, you may want to consider the latter to get more counseling for special health needs, says Marc Hoffing, medical director of the Oasis Independent Physician Association in Palm Springs, Calif., which contracts with managed-care plans. For the sickest patients in the Medicare managed-care plans that Mr. Hoffing's association serves, case managers are available 24 hours a day.
FIND A SUPPORT GROUP
In Washington state, Colorado, Northern California and a few other pockets around the country, doctors who work with older people are experimenting with grouping those patients together for appointments, even if, in some cases, they suffer from different health problems.
Such visits have proved so popular at Group Health Cooperative in Seattle that the nonprofit health-care system has expanded its pilot project to 20 locations, says Martin Levine, Group Health's medical director for senior care. Patients in the groups use the emergency room less, a big cost saver, and have seen their health improve in other ways.
The group visits start with an icebreaker, then move into a 30-minute discussion about a topic the patients agreed on the previous month, such as how to manage your medications, what happens if you're traveling and get sick, how to monitor high blood pressure, how to manage vision and hearing loss, and so forth. Then the group takes a coffee break, during which the doctors check in with people individually. In the last 10 minutes, the group decides what to talk about the following month.
"The patients come in with a whole mix of problems -- diabetes, heart disease, lung disease, arthritis," says Dr. Levine. "Over time, they realize they don't need their one-on-one visits so much." The patients often benefit from hearing their doctors' advice reinforced by people their own age, he adds.
"One doctor saw someone with headaches that had no explanation for eight years," says Dr. Levine. The doctor "ran out of things to offer her and told her to go out there, stay active, go for a walk. At a group visit, one woman told her, 'I go for a walk every day. You should go for a walk.' The woman with the headaches said, 'That's a good idea,' and they traded phone numbers." The two became walking partners, and the headaches went away.
LEARN MORE ABOUT HEALTH
Take the time to learn about health basics like nutrition or what preventive tests are appropriate at what ages.
One basic tool: a self-help health-care manual, such as "Healthwise for Life," co-authored by Ms. Mettler of Healthwise Inc., or the "Merck Manual of Health and Aging." Forty percent of patients in one study in Southern California who were given a self-care book reported saving a trip to the doctor's office; 39% said they saved a trip to the emergency room.
You also should get copies of your medical records, either online or on paper, says Beverly Bernstein Joie, president of Elder Connections Inc., a geriatric-care-management company in suburban Philadelphia. You are entitled to your medical records by law.
For instance, when you see a specialist, such as a cardiologist, ask for a copy of your cardiogram and the report that goes to other physicians. That way, Ms. Joie says, if results and reports don't make it to other doctors, you have a backup copy and can still get the most out of future health-care appointments.
MOVE OFFSHORE
It might sound extreme, but some retirees are moving to Costa Rica, Mexico and other countries where health-care costs are appreciably lower and the quality of service, they say, is significantly better.
Several years ago, Robert Preston, an actuary in Sarasota, Fla., was frustrated with the lack of medical and custodial attention his father, the retired chief financial officer of a large pharmaceutical company, was receiving in Florida. Expenses totaled $10,000 a month for a room in a nursing home in Venice Beach, as well as personal attendants.
Mr. Preston started thinking about pursuing care for his father in another country. He settled on Costa Rica after a friend returned from a trip there, singing the praises of the country's medical services. Eventually, Mr. Preston's father settled in a private home in Costa Rica, with a house manager, chauffeur and three attendants -- all for about $3,000 a month. Instead of being confined to a nursing home, his father attended church every Sunday, took a large group to brunch afterward, went out to dinner several times a week -- and occasionally even went on a date. (Mr. Preston flew down to see his father once a month on a four-hour flight to San Jose, rather than a three-hour flight to Florida.)
Mr. Preston's father died in 2001. Since then, two of Mr. Preston's friends have moved family there.
"In Costa Rica, the medical system is excellent. My father's doctor there would call me up in Connecticut," Mr. Preston says. "I couldn't get doctors in Florida to return my phone calls."
Thursday, August 10, 2006
Caps on Noneconomic Damages
Attached a letter to the editor sent to the Miami Herald commenting on the interview with Lewis Eidson,the new president of the Association of Trial Lawyers of America published in the Miami Herald on August 7th, 2006.
"In your interview with Lewis S. Eidson(08/07/06), the new president of the Association of Trial lawyers claims that caps on medical professional liability do not affect insurance premiums. This is flatly wrong. In September 2003 voters in Texas approved Proposition 12, a constitutional amendment that caps noneconomic medical malpractice damages at $250,000. Since the passage of this amendment the state's largest provider of medical malpractice insurance reduced rates by 12 percent in 2004, 5 percent in 2005 and an additional 5 percent in 2006. This resulted in the return of $10 million in dividends to 2005 policyholders. The drastic readjustment of insurance rates allows many doctors in high-risk specialties (OBGyn, Surgery, Neurosurgery) to continue practicing medicine and guarantees access to medical care for citizens in Texas. Imagine this would happen in Florida? We would not have to struggle to retain neurosurgeons and obstetricians and lives could be saved by preventing treatment delays for patients with serious head injuries and women seeking skilled obstetricians for complicated deliveries. Mr.Eidson’s callous disregard for our citizens’ health is appalling."
"In your interview with Lewis S. Eidson(08/07/06), the new president of the Association of Trial lawyers claims that caps on medical professional liability do not affect insurance premiums. This is flatly wrong. In September 2003 voters in Texas approved Proposition 12, a constitutional amendment that caps noneconomic medical malpractice damages at $250,000. Since the passage of this amendment the state's largest provider of medical malpractice insurance reduced rates by 12 percent in 2004, 5 percent in 2005 and an additional 5 percent in 2006. This resulted in the return of $10 million in dividends to 2005 policyholders. The drastic readjustment of insurance rates allows many doctors in high-risk specialties (OBGyn, Surgery, Neurosurgery) to continue practicing medicine and guarantees access to medical care for citizens in Texas. Imagine this would happen in Florida? We would not have to struggle to retain neurosurgeons and obstetricians and lives could be saved by preventing treatment delays for patients with serious head injuries and women seeking skilled obstetricians for complicated deliveries. Mr.Eidson’s callous disregard for our citizens’ health is appalling."
Friday, August 04, 2006
Retail Clinics: The Smart Response
Retail clinics in shopping center are spreading across the US fueled by the demand for “cheap” and accessible health care. Most of them are staffed by nurse practitioners and offer treatments for minor aches and pains. Many doctors and medical organizations have expressed their concerns that such clinics may siphon of patients from their traditional medical practices thereby jeopardizing their bottom-line. Furthermore, the quality of care rendered at those clinics is being questioned, especially in the absence of licensed doctors on-site. All of the above points are justified and valid, but the fact remains that many under- or uninsured seeking an alternative to the existing system of long-waits at bursting ERs or in crowded doctor waiting rooms. We should consider adopting and changing our practices to meet their demands and needs thereby attracting those potential patients to our medical practices. Now, traditional medical providers are stepping up to the counter, driven by the threat of new competition, the opportunity to recruit new patients -- and real concerns about the quality of care. Some large regional health-care systems are starting their own clinics directly with retail partners, while other medical groups and doctors offices are signing contracts to supervise clinic staff, and striking up referral arrangements with retail clinics. If you can fight them, join them!
The New Force In Walk-In Clinics Hospitals and Doctors Seek
Slice of Burgeoning Business; Getting Referrals at ShopRite
WSJ July 26, 2006; Page D1
(See Corrections & Amplifications item below.)
With catchy slogans like "You're Sick! We're Quick!" retail health clinics are spreading fast in supermarkets, drugstores and big-box chains across the country, luring patients with walk-in treatment for minor ailments like strep throat -- at about half the cost of a typical doctor visit.
The phenomenon has been largely driven by small start-up chains, such as MinuteClinic, RediClinic and Take Care Health Systems, which run the outlets under agreement with retailers and have had few formal ties to the medical establishment.
Now, traditional medical providers are stepping up to the counter, driven by the threat of new competition, the opportunity to recruit new patients -- and real concerns about the quality of care. Some large regional health-care systems are starting their own clinics directly with retail partners, while other medical groups and doctors offices are signing contracts to supervise clinic staff, and striking up referral arrangements with retail clinics.
In southeastern New Jersey, for example, AtlantiCare, the region's largest health-care system with about 450 staff physicians and a network that includes two hospitals and a health plan, will open its first in-store HealthRite clinic next month in a Somers Point, N.J., ShopRite supermarket. It's the first of seven initially planned, and the company may also franchise to other health systems. Geisinger Health System, of Danville, Pa., with hospitals, physician practices and other health services, is opening its first CareWorks Convenient Healthcare clinic in the Weis Markets grocery chain next month, and will open as many as 75 sites throughout the region in the next five years. Memorial Baptist Health system in South Bend, Ind., is operating Medpoint express centers in local Wal-Mart Super Centers.
Staffed mainly by nurse practitioners who are licensed to treat a wide range of minor illnesses and prescribe medications, retail clinics have grown rapidly over the past five years as retailers, including CVS, Kroger, Wal-Mart Stores and Walgreen, have signed up with more than a half-dozen clinic operators. Earlier this month, CVS, with 6,100 retail outlets, agreed to acquire MinuteClinic, which currently operates 83 clinics in outlets including CVS, Bartell Drugs and QFC Foods in markets such as Baltimore; Nashville, Tenn.; and Washington, D.C., suburbs, and plans to add more than 1,000 by 2009.
By the end of the decade, the number of clinics could grow nearly tenfold to 10,000, says Peter Miller, chief executive officer of Take Care Health, which runs 16 clinics in Walgreens and Rite Aid drugstores in Portland, Ore., Kansas City, Mo., and St. Louis. Take Care plans to open 1,400 clinics by 2009. "We're offering health care on patients' terms instead of on the health-care system's terms," says Mr. Miller.
While some experts question whether the clinics can generate adequate profits for operators and retailers, by opening their own clinics or signing referral agreements, hospitals and physicians can capture a piece of the action at a time when competition for patients is a growing concern. In a new report, the California HealthCare Foundation predicts that retail clinics "could change the way many people receive routine, non-urgent medical care."
Last month, the American Medical Association and the American Academy of Family Physicians warned that retail clinics with no ties to health-care systems could lead to more fragmentation of patient care, inadequate follow-up for patients, and missed opportunities for preventive care. Both groups called on the clinic operators to ensure that clinics are supervised by doctors and to establish formal referral systems with local doctors and hospitals.
Relying on retail clinics for care does carry certain risks. The clinics typically don't have private exam rooms or physicians on site -- though state regulations require nurse practitioners to have some level of oversight by a sponsoring physician. Clinics generally don't have procedures for follow-up with repeat visits. And because they don't do comprehensive physical exams or the most sophisticated tests, doctors warn, the clinics may miss more-serious conditions.
Traditional health-care providers say that the new wave of clinics that they operate or support will have advantages over independent clinics. Larger medical facilities have more experience to provide training, and the relationships will allow greater continuity of care, including sharing of medical records. They say they will be able to quickly link patients with a doctor or hospital if need be, but their clinic charges and costs will be comparable with those of the independent clinics.
Patrick Nemechek, a Kansas City internist sought a referral arrangement with Take Care clinics near his office. "Part of the reason these clinics are doing so well is the failure of the health-care system to take care of the consumer's needs," says Dr. Nemechek. He often sends patients with "quick, simple" issues to Take Care clinics, while the clinic refers patients with more serious concerns such as a spike in blood pressure.
In St. Louis, SSM Health Care, with eight hospitals and nearly 2,000 staff physicians, recently agreed to help supervise Take Care clinics in the area and review medical records to ensure care is appropriate; Take Care will refer patients with more serious health-care issues to SSM doctors, where they can establish continuing relationships. "We see this as an opportunity to participate in an evolution of health care but also to help shape it in a way that serves patients first," says SSM regional president, Ron Levy.
When Take Care signed an agreement to open 20 Health Corner clinics in Chicago Walgreens stores this fall, it also struck a deal with Advocate Health Partners, Oak Brook, Ill., which includes more than 900 primary-care physicians and 1,800 specialists, for each to refer patients to the other. Advocate doctors will review clinic medical records and supervise nurse practitioners.
Memorial Hermann Healthcare System in Houston and Hillcrest Medical Center in Tulsa, Okla., are providing medical oversight for RediClinic, a unit of Houston-based InterFit Health, which has 75 clinics in retailers such as Duane Reade, H-E-B grocery stores, Wal-Mart and Walgreens, and plans to open 500 new units by 2009.
Some health systems see more advantages to entering the clinic market directly. "As a local health system we think it's important to provide new levels of access to health care for patients, and to compete in areas where private entrepreneurs are rushing in," says Don Parker, president of the AtlantiCare unit that is opening HealthRite clinics in ShopRite stores. While clinics may compete with AtlantiCare's own staff doctors, he says, clinics can treat minor ailments and allow doctors "to concentrate on more complex issues of care and patients with chronic conditions."
AtlantiCare clinics will offer tips for healthy grocery shopping, and AtlantiCare is talking to ShopRite about offering nutritional tours of the supermarket aisles and better labeling of foods for healthy diets.
Clinic operators say they have reached out to local physicians to supervise nurse practitioners, and sought to establish referral relationships with doctors, urgent-care centers and emergency rooms. James Woodburn, a physician who is MinuteClinic's chief medical officer, says he sends letters to physicians in each market the company enters to ask if they are accepting new patients, and if so adds them to a database for referrals.
Retail-clinic operators say that sometimes nurse practitioners do fail to recognize more-serious illness, but that nothing has given rise to any legal action (clinics generally carry some malpractice insurance). The bottom line, they say, is that retail clinics fill a need, take steps to ensure care is high-quality, and encourage patients to seek regular care from a doctor.
Uninsured patients pay cash, while insured patients are charged a co-pay that may be slightly more or less than what they have to pay at the doctor's office, depending on the clinic. Take Care clinics bill insurers 10% to 30% less than doctors do, Mr. Miller says.
Blue Cross & Blue Shield of Minnesota, which analyzed 22,956 visits by its members to MinuteClinics from June 2004 to June 2005, found the clinics cost about half an office visit -- or $43 versus $87 -- and less than half for other related costs such as lab services.
Chris Shandrow, a 29-year-old creative-arts director at a local church, sought care for a pesky sinus infection at a Walgreens clinic operated by Take Care, when he first moved to the Kansas City area with his wife and children without a primary-care doctor. He was in and out with a prescription within 10 minutes and was charged a $20 co-pay. "I know I'm going to need to get a regular doctor, but the convenience of being able to pop in there was really worth it," he says.
• Email me at informedpatient@wsj.com1.
Corrections & Amplifications:
Memorial Health System of South Bend, Ind., is operating Medpoint express health clinics in Indiana. This column incorrectly identified as Memorial Baptist Health.
The New Force In Walk-In Clinics Hospitals and Doctors Seek
Slice of Burgeoning Business; Getting Referrals at ShopRite
WSJ July 26, 2006; Page D1
(See Corrections & Amplifications item below.)
With catchy slogans like "You're Sick! We're Quick!" retail health clinics are spreading fast in supermarkets, drugstores and big-box chains across the country, luring patients with walk-in treatment for minor ailments like strep throat -- at about half the cost of a typical doctor visit.
The phenomenon has been largely driven by small start-up chains, such as MinuteClinic, RediClinic and Take Care Health Systems, which run the outlets under agreement with retailers and have had few formal ties to the medical establishment.
Now, traditional medical providers are stepping up to the counter, driven by the threat of new competition, the opportunity to recruit new patients -- and real concerns about the quality of care. Some large regional health-care systems are starting their own clinics directly with retail partners, while other medical groups and doctors offices are signing contracts to supervise clinic staff, and striking up referral arrangements with retail clinics.
In southeastern New Jersey, for example, AtlantiCare, the region's largest health-care system with about 450 staff physicians and a network that includes two hospitals and a health plan, will open its first in-store HealthRite clinic next month in a Somers Point, N.J., ShopRite supermarket. It's the first of seven initially planned, and the company may also franchise to other health systems. Geisinger Health System, of Danville, Pa., with hospitals, physician practices and other health services, is opening its first CareWorks Convenient Healthcare clinic in the Weis Markets grocery chain next month, and will open as many as 75 sites throughout the region in the next five years. Memorial Baptist Health system in South Bend, Ind., is operating Medpoint express centers in local Wal-Mart Super Centers.
Staffed mainly by nurse practitioners who are licensed to treat a wide range of minor illnesses and prescribe medications, retail clinics have grown rapidly over the past five years as retailers, including CVS, Kroger, Wal-Mart Stores and Walgreen, have signed up with more than a half-dozen clinic operators. Earlier this month, CVS, with 6,100 retail outlets, agreed to acquire MinuteClinic, which currently operates 83 clinics in outlets including CVS, Bartell Drugs and QFC Foods in markets such as Baltimore; Nashville, Tenn.; and Washington, D.C., suburbs, and plans to add more than 1,000 by 2009.
By the end of the decade, the number of clinics could grow nearly tenfold to 10,000, says Peter Miller, chief executive officer of Take Care Health, which runs 16 clinics in Walgreens and Rite Aid drugstores in Portland, Ore., Kansas City, Mo., and St. Louis. Take Care plans to open 1,400 clinics by 2009. "We're offering health care on patients' terms instead of on the health-care system's terms," says Mr. Miller.
While some experts question whether the clinics can generate adequate profits for operators and retailers, by opening their own clinics or signing referral agreements, hospitals and physicians can capture a piece of the action at a time when competition for patients is a growing concern. In a new report, the California HealthCare Foundation predicts that retail clinics "could change the way many people receive routine, non-urgent medical care."
Last month, the American Medical Association and the American Academy of Family Physicians warned that retail clinics with no ties to health-care systems could lead to more fragmentation of patient care, inadequate follow-up for patients, and missed opportunities for preventive care. Both groups called on the clinic operators to ensure that clinics are supervised by doctors and to establish formal referral systems with local doctors and hospitals.
Relying on retail clinics for care does carry certain risks. The clinics typically don't have private exam rooms or physicians on site -- though state regulations require nurse practitioners to have some level of oversight by a sponsoring physician. Clinics generally don't have procedures for follow-up with repeat visits. And because they don't do comprehensive physical exams or the most sophisticated tests, doctors warn, the clinics may miss more-serious conditions.
Traditional health-care providers say that the new wave of clinics that they operate or support will have advantages over independent clinics. Larger medical facilities have more experience to provide training, and the relationships will allow greater continuity of care, including sharing of medical records. They say they will be able to quickly link patients with a doctor or hospital if need be, but their clinic charges and costs will be comparable with those of the independent clinics.
Patrick Nemechek, a Kansas City internist sought a referral arrangement with Take Care clinics near his office. "Part of the reason these clinics are doing so well is the failure of the health-care system to take care of the consumer's needs," says Dr. Nemechek. He often sends patients with "quick, simple" issues to Take Care clinics, while the clinic refers patients with more serious concerns such as a spike in blood pressure.
In St. Louis, SSM Health Care, with eight hospitals and nearly 2,000 staff physicians, recently agreed to help supervise Take Care clinics in the area and review medical records to ensure care is appropriate; Take Care will refer patients with more serious health-care issues to SSM doctors, where they can establish continuing relationships. "We see this as an opportunity to participate in an evolution of health care but also to help shape it in a way that serves patients first," says SSM regional president, Ron Levy.
When Take Care signed an agreement to open 20 Health Corner clinics in Chicago Walgreens stores this fall, it also struck a deal with Advocate Health Partners, Oak Brook, Ill., which includes more than 900 primary-care physicians and 1,800 specialists, for each to refer patients to the other. Advocate doctors will review clinic medical records and supervise nurse practitioners.
Memorial Hermann Healthcare System in Houston and Hillcrest Medical Center in Tulsa, Okla., are providing medical oversight for RediClinic, a unit of Houston-based InterFit Health, which has 75 clinics in retailers such as Duane Reade, H-E-B grocery stores, Wal-Mart and Walgreens, and plans to open 500 new units by 2009.
Some health systems see more advantages to entering the clinic market directly. "As a local health system we think it's important to provide new levels of access to health care for patients, and to compete in areas where private entrepreneurs are rushing in," says Don Parker, president of the AtlantiCare unit that is opening HealthRite clinics in ShopRite stores. While clinics may compete with AtlantiCare's own staff doctors, he says, clinics can treat minor ailments and allow doctors "to concentrate on more complex issues of care and patients with chronic conditions."
AtlantiCare clinics will offer tips for healthy grocery shopping, and AtlantiCare is talking to ShopRite about offering nutritional tours of the supermarket aisles and better labeling of foods for healthy diets.
Clinic operators say they have reached out to local physicians to supervise nurse practitioners, and sought to establish referral relationships with doctors, urgent-care centers and emergency rooms. James Woodburn, a physician who is MinuteClinic's chief medical officer, says he sends letters to physicians in each market the company enters to ask if they are accepting new patients, and if so adds them to a database for referrals.
Retail-clinic operators say that sometimes nurse practitioners do fail to recognize more-serious illness, but that nothing has given rise to any legal action (clinics generally carry some malpractice insurance). The bottom line, they say, is that retail clinics fill a need, take steps to ensure care is high-quality, and encourage patients to seek regular care from a doctor.
Uninsured patients pay cash, while insured patients are charged a co-pay that may be slightly more or less than what they have to pay at the doctor's office, depending on the clinic. Take Care clinics bill insurers 10% to 30% less than doctors do, Mr. Miller says.
Blue Cross & Blue Shield of Minnesota, which analyzed 22,956 visits by its members to MinuteClinics from June 2004 to June 2005, found the clinics cost about half an office visit -- or $43 versus $87 -- and less than half for other related costs such as lab services.
Chris Shandrow, a 29-year-old creative-arts director at a local church, sought care for a pesky sinus infection at a Walgreens clinic operated by Take Care, when he first moved to the Kansas City area with his wife and children without a primary-care doctor. He was in and out with a prescription within 10 minutes and was charged a $20 co-pay. "I know I'm going to need to get a regular doctor, but the convenience of being able to pop in there was really worth it," he says.
• Email me at informedpatient@wsj.com1.
Corrections & Amplifications:
Memorial Health System of South Bend, Ind., is operating Medpoint express health clinics in Indiana. This column incorrectly identified as Memorial Baptist Health.
Medicare and Hospital Payments
The Bush administration has decided to scale back its proposed changes in Medicare payments to hospitals including the proposed payment cuts for many complex treatments. Medicare pays more than $125 billion a year to nearly 5,000 hospitals. Federal officials had proposed sweeping changes in the classification system, to account for the severity of each patient’s illness. They wanted to replace the 526 categories with 861. They settled for more modest changes in 2007, creating 20 diagnostic groups and altering 32 others. Even though, this may appear like a victory it may have negative repercussion in our battle to stop proposed Medicare cuts for physicians. The pie does not get bigger and each of us is fighting for a larger slice. In this battle the administration plays one group against the other according to the old roman principle “divide and rule”. Instead of fighting each other e need to unite to demand for a substantial reform of the entire Medicare payment and reimbursement system.
NYT August 3, 2006
Scaling Back Changes to Medicare Payments
By ROBERT PEAR
WASHINGTON, Aug. 2 — Under intense pressure from health care lobbyists and lawmakers, the Bush administration says it will scale back and delay proposed changes in Medicare payments to hospitals that would have created clear winners and losers.
The proposals would have cut payments by 20 percent to 30 percent for many complex treatments and new technologies. Hospitals will instead see much smaller cuts or even small increases for many of those procedures. Some of the changes will be phased in over three years.
Doctors, hospitals, consumer groups and members of Congress had said the proposed cuts would be devastating. Under the proposals, they said, patients would have had less access to some services like cardiac care.
On Tuesday night, the Bush administration issued a final rule that reaffirmed the overall goal of more accurate payments while backing away from many of the proposed changes, including a sweeping revision in the classification of patients intended to account for the severity of their illnesses.
The reaction from Wall Street analysts on Wednesday was positive.
“The final rule significantly moderates proposed cuts for cardiac procedures,’’ Citigroup said in a note to investors. Lehman Brothers described the final rule as “a win for cardiac and orthopedic device companies, specialty hospitals and general acute care hospitals.’’ The Prudential Equity Group said the final rule, which takes effect on Oct. 1, was “favorable for device manufacturers’’ like Boston Scientific, Medtronic and St. Jude Medical.
Stephen J. Ubl, president of the Advanced Medical Technology Association, which represents hundreds of device makers, said he was pleased that the Bush administration and Medicare officials had responded to the industry’s concerns.
The new rule removes “a dark cloud’’ that had been hovering over the industry, Mr. Ubl said, adding, “The worst is behind us.’’
The industry’s lobbying campaign offers a case study in how to influence the government on complex technical issues that have implications worth billions of dollars to a politically potent sector of the economy.
Rather than just filing comments on the proposed rule, the health care industry mobilized a political campaign that combined advertising and lobbying to beat back the proposed cuts. Lobbyists wrote dozens of letters to the Medicare agency, stoked concern on Capitol Hill, ran advertisements and met with White House officials including Rob Portman, the new director of the Office of Management and Budget.
Under the proposal, published in April, the basic Medicare payment for surgery to open clogged arteries, by inserting a drug-coated wire mesh stent, would have been cut by 33 percent, to $7,590. The final rule calls instead for a cut of 3 percent, so Medicare will pay about $11,000.
The payment for implanting a defibrillator, like the one used by Vice President Dick Cheney, would have been cut 23 percent under the proposal, to $22,000. The final rule calls for a cut of 2 percent, so Medicare will pay about $27,750.
Under the final rule, hospitals will receive much smaller increases than originally proposed for treating some conditions, like pneumonia and chronic obstructive pulmonary disease.
Michael O. Leavitt, the secretary of health and human services, said the current payment system was full of biases and distortions that encouraged hospitals to provide “treatments that happen to be the most profitable.’’
Federal officials said the new payments would be more accurate because they would be based on estimated hospital costs, rather than inflated charges. In revising its proposal, the government significantly modified its method of estimating costs, to include more data from high-cost hospitals. The resulting changes will be smaller than originally proposed and will be put into effect gradually over three years, rather than all at once.
Dr. Mark B. McClellan, administrator of the Centers for Medicare and Medicaid Services, said the final rule would mean “smaller changes in payment, up or down, than the proposed rule.’’
Medicare pays more than $125 billion a year to nearly 5,000 hospitals. Hospitals typically receive a fixed amount for each Medicare patient, regardless of how long the person stays in the hospital. Each patient is classified in one of 526 categories, known as diagnosis-related groups.
Federal officials had proposed sweeping changes in the classification system, to account for the severity of each patient’s illness. They wanted to replace the 526 categories with 861. They settled for more modest changes in 2007, creating 20 diagnostic groups and altering 32 others.
The severity of a patient’s illness can have a significant effect on the costs of care. In trying to account for those costs, the proposed rule relied heavily on a patient-classification system devised by 3M, the technology company based in Minnesota.
Hospitals said Medicare should not rely on a proprietary system controlled by a single company.
The Bush administration agreed to consider alternatives, to ensure that no company would have a monopoly over the software needed to manage billing and payment.
NYT August 3, 2006
Scaling Back Changes to Medicare Payments
By ROBERT PEAR
WASHINGTON, Aug. 2 — Under intense pressure from health care lobbyists and lawmakers, the Bush administration says it will scale back and delay proposed changes in Medicare payments to hospitals that would have created clear winners and losers.
The proposals would have cut payments by 20 percent to 30 percent for many complex treatments and new technologies. Hospitals will instead see much smaller cuts or even small increases for many of those procedures. Some of the changes will be phased in over three years.
Doctors, hospitals, consumer groups and members of Congress had said the proposed cuts would be devastating. Under the proposals, they said, patients would have had less access to some services like cardiac care.
On Tuesday night, the Bush administration issued a final rule that reaffirmed the overall goal of more accurate payments while backing away from many of the proposed changes, including a sweeping revision in the classification of patients intended to account for the severity of their illnesses.
The reaction from Wall Street analysts on Wednesday was positive.
“The final rule significantly moderates proposed cuts for cardiac procedures,’’ Citigroup said in a note to investors. Lehman Brothers described the final rule as “a win for cardiac and orthopedic device companies, specialty hospitals and general acute care hospitals.’’ The Prudential Equity Group said the final rule, which takes effect on Oct. 1, was “favorable for device manufacturers’’ like Boston Scientific, Medtronic and St. Jude Medical.
Stephen J. Ubl, president of the Advanced Medical Technology Association, which represents hundreds of device makers, said he was pleased that the Bush administration and Medicare officials had responded to the industry’s concerns.
The new rule removes “a dark cloud’’ that had been hovering over the industry, Mr. Ubl said, adding, “The worst is behind us.’’
The industry’s lobbying campaign offers a case study in how to influence the government on complex technical issues that have implications worth billions of dollars to a politically potent sector of the economy.
Rather than just filing comments on the proposed rule, the health care industry mobilized a political campaign that combined advertising and lobbying to beat back the proposed cuts. Lobbyists wrote dozens of letters to the Medicare agency, stoked concern on Capitol Hill, ran advertisements and met with White House officials including Rob Portman, the new director of the Office of Management and Budget.
Under the proposal, published in April, the basic Medicare payment for surgery to open clogged arteries, by inserting a drug-coated wire mesh stent, would have been cut by 33 percent, to $7,590. The final rule calls instead for a cut of 3 percent, so Medicare will pay about $11,000.
The payment for implanting a defibrillator, like the one used by Vice President Dick Cheney, would have been cut 23 percent under the proposal, to $22,000. The final rule calls for a cut of 2 percent, so Medicare will pay about $27,750.
Under the final rule, hospitals will receive much smaller increases than originally proposed for treating some conditions, like pneumonia and chronic obstructive pulmonary disease.
Michael O. Leavitt, the secretary of health and human services, said the current payment system was full of biases and distortions that encouraged hospitals to provide “treatments that happen to be the most profitable.’’
Federal officials said the new payments would be more accurate because they would be based on estimated hospital costs, rather than inflated charges. In revising its proposal, the government significantly modified its method of estimating costs, to include more data from high-cost hospitals. The resulting changes will be smaller than originally proposed and will be put into effect gradually over three years, rather than all at once.
Dr. Mark B. McClellan, administrator of the Centers for Medicare and Medicaid Services, said the final rule would mean “smaller changes in payment, up or down, than the proposed rule.’’
Medicare pays more than $125 billion a year to nearly 5,000 hospitals. Hospitals typically receive a fixed amount for each Medicare patient, regardless of how long the person stays in the hospital. Each patient is classified in one of 526 categories, known as diagnosis-related groups.
Federal officials had proposed sweeping changes in the classification system, to account for the severity of each patient’s illness. They wanted to replace the 526 categories with 861. They settled for more modest changes in 2007, creating 20 diagnostic groups and altering 32 others.
The severity of a patient’s illness can have a significant effect on the costs of care. In trying to account for those costs, the proposed rule relied heavily on a patient-classification system devised by 3M, the technology company based in Minnesota.
Hospitals said Medicare should not rely on a proprietary system controlled by a single company.
The Bush administration agreed to consider alternatives, to ensure that no company would have a monopoly over the software needed to manage billing and payment.
Saturday, July 22, 2006
Medicare Part D and Soaring Profits
The New York Times featured an article, which contained some troublesome (but predictable) information about Medicare Part D. The pharmaceutical industry is beginning to reap a windfall from a surprisingly lucrative niche market: drugs for poor people. The windfall, which by some estimates could be $2 billion or more this year, is a result of the transfer of millions of low-income people into the new Medicare Part D drug program that went into effect in January. Under that program, as it turns out, the prices paid by insurers, and eventually the taxpayer, for the medications given to those transferred are likely to be higher than what was paid under the federal-state Medicaid programs for the poor. About 6.5 million low-income elderly people or younger disabled poor people were automatically transferred into the Part D program for drug coverage. Because their other health needs are still covered by Medicaid, they are called dual eligibles.The advent of Part D has not affected the drug coverage for the 45 million other low-income people whose drugs are still paid for under state Medicaid programs. Those programs closely monitor drug prices, and drug makers often typically end up paying rebates to the states.That means that taxpayers fund the soaring profits for insurance companies. I hope that this information will guide us to vote those politicians of the island , who supported this program . Most of them are REPUBLICANS!!! Oh, did I forget to mention that UnitedHealth Group Inc. reported a 26% increase in second-quarter profit, reflecting an acquisition and strong enrollment in its new Medicare drug-benefit plan.!! Thats your taxes at work!!
NYT July 18, 2006
Market Place
A Windfall From Shifts to Medicare
By MILT FREUDENHEIM
The pharmaceutical industry is beginning to reap a windfall from a surprisingly lucrative niche market: drugs for poor people.
And analysts expect the benefits to show up in many of the quarterly financial results that drug makers will begin posting this week.
The windfall, which by some estimates could be $2 billion or more this year, is a result of the transfer of millions of low-income people into the new Medicare Part D drug program that went into effect in January. Under that program, as it turns out, the prices paid by insurers, and eventually the taxpayer, for the medications given to those transferred are likely to be higher than what was paid under the federal-state Medicaid programs for the poor.
About 6.5 million low-income elderly people or younger disabled poor people were automatically transferred into the Part D program for drug coverage. Because their other health needs are still covered by Medicaid, they are called dual eligibles.
The advent of Part D has not affected the drug coverage for the 45 million other low-income people whose drugs are still paid for under state Medicaid programs. Those programs closely monitor drug prices, and drug makers often typically end up paying rebates to the states.
It is too early to calculate the full effect of the shift of the former Medicaid patients now covered by Part D. But analysts expect it to generate hundreds of millions of additional dollars this year for the drug companies, which have long chafed under the pricing restraints of the state programs.
Drugs tend to be cheaper under the Medicaid programs because the states are the buyers and by law they receive the lowest available prices for drugs.
But in creating the federal Part D program, Congress — in what critics saw as a sop to the drug industry — barred the government from having a negotiating role. Instead, prices are worked out between drug makers and the dozens of large and small Part D drug plans run by commercial insurers.
Since Part D went into effect, the pharmaceutical industry has raised the wholesale prices of its brand-name drugs an average of 3.6 percent. Although the actual amount spent depends on what each insurer negotiates, in many cases the drugs for those 6.5 million people who used to receive their medicines through Medicaid will cost more now.
Initially, the added costs will be paid by the insurers administering the new Medicare drug program. But when it comes time for the insurers to settle accounts with the government, the costs of the 6.5 million drugs for the transferees will end up being passed along to federal taxpayers, according to analysts and health care economists.
The windfall for the drug makers was made possible by a provision of the 2003 Medicare law that exempts Part D drugs from “best price” rebates that the drug makers have been required to give to the state Medicaid programs since 1991. Those rebates are meant to make sure that state Medicaid agencies pay no more than the best prices drug companies offer to any big commercial insurer.
Under Medicaid, the federal government and state agencies paid more than $14 billion annually for the drugs of the 6.5 million transferees. Without the best-price rebates, the cost would have been 25 percent higher, or about $17.5 billion, said Stephen W. Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota.
Nobody yet knows what the total drug bill will be for these people under Part D, beyond the assumption by many experts that it will be higher. Medicare will not have solid numbers until it can analyze the hundreds of monthly reports that the plans in the Part D system are required to file.
Yet, one indicator of the higher revenue from dual-eligibles has already been seen in reports by drug companies this year showing double-digit United States sales increases of certain drugs that are heavily used by Medicaid patients. For example, sales of Lamictal, an antipsychosis drug from GlaxoSmithKline, were up 33 percent, to $305 million in the first quarter; sales of Seroquel, an antipsychotic from AstraZeneca, were up 29 percent, to $590 million; and sales of Plavix, a blood thinner from Bristol-Myers Squibb, were up 26 percent, to $850 million.
Timothy Anderson, a pharmaceutical analyst with the Prudential Equity Group, estimates that if Part D were not in place the rebates for the makers for all of 2006 would have been more than $2 billion for 13 drugs widely used by the people transferred from Medicaid to Part D.
Dr. Anderson estimates that because the companies will not have to pay those rebates under Part D, revenue to Glaxo from Lamictal will increase by $298 million this year, AstraZeneca’s Seroquel sales will rise by $521 million, and Plavix revenue will increase $169 million. Estimates on the rebate increases because of Part D are few, but all are in general agreement on the size of the rebate to drug makers.
Medicaid programs have been especially important for drugs like Seroquel and Lamictal, which are prescribed for bipolar disorder and other mental health problems
About two million of the people transferred to Part D are disabled and younger than 65, and “more than half of them have mental health problems,” said Jim Verdier, a senior fellow at Mathematica Policy Research in Washington and a former Medicaid director in Indiana. “In the past, Medicaid was 80 to 90 percent of the total market for some high-end antipsychotic drugs,” Mr. Verdier said.
Over all, the Medicaid best-price rebates have averaged about 15 percent of the list prices of the manufacturers, but some states, including California, New York and Maine have obtained even larger rebates, Professor Schondelmeyer said.
Now, under Part D, all sorts of price deals will be negotiated by dozens of Medicare drug plans, large and small. The prices will be reported to Medicare, but under a provision of the law pushed by industry lobbyists, they will otherwise be kept secret.
Mark B. McClellan, administrator of the federal agency that oversees Medicare and Medicaid, said that the lowest-cost plans among the Part D offerings by commercial insurers were now getting “significantly better prices than Medicaid.” But he did not provide specifics.
Dr. McClellan also noted that his agency was requiring the states to return a combined total of $5.8 billion to Washington from federal funds dispensed to the Medicaid program. That money is based on a federal estimate of the amount states will be saving by no longer having to provide drugs to the dual-eligibles.
But the states, disparaging those refunds as “clawbacks,’’ have disputed the federal formula that was the basis for the repayments. Last month, the Supreme Court declined to hear a case filed by the attorneys general of Texas and four other states seeking to quash the repayment formula as unconstitutional.
Now the plaintiffs, which also include Kentucky, Maine, Missouri, and New Jersey, are expected to take the fight to lower courts. Ten other states have supported the plaintiffs.
The states say the federal formula assumes higher drug costs than many Medicaid programs have been spending.
“We get 32 percent back in drug rebates,” said Jude E. Walsh, a special assistant to Governor John Baldacci of Maine. She said Maine’s Medicaid drug costs were rising only 2 percent to 3 percent a year, compared with national trends that are three to four times that.
The drug companies, for their part, have played down the size of the expected windfall from Medicaid transferees. And Bush administration officials say they do not know how much they will end up spending on those people. “No one is willing to quantify it,” said Dr. Anderson, the Prudential analyst.
In one of the few public comments by a drug company official, Derica W. Rice, chief financial officer of Eli Lilly, told analysts on a conference call in April that Lilly expected “modest price benefits due to lower rebates as patients move from Medicaid to Plan D.”
Zyprexa, a Lilly drug for schizophrenia, is another medication widely prescribed for Medicaid patients.
The drug makers do have reason to worry about long-run prospects under the vast new Medicare Part D program. There are currently 81 Part D drug plan sponsors, large and small, with varying degrees of negotiating power. But the plans are expected eventually to merge into a handful of large survivors, each of them presumably having more bargaining power with drug companies.
A further concern is that as the true costs of Part D become known, Congress may eventually impose spending ceilings.
For now though, as the drug industry begins to report its quarterly profits, the market for those 6.5 million poor people is likely to look rather
NYT July 18, 2006
Market Place
A Windfall From Shifts to Medicare
By MILT FREUDENHEIM
The pharmaceutical industry is beginning to reap a windfall from a surprisingly lucrative niche market: drugs for poor people.
And analysts expect the benefits to show up in many of the quarterly financial results that drug makers will begin posting this week.
The windfall, which by some estimates could be $2 billion or more this year, is a result of the transfer of millions of low-income people into the new Medicare Part D drug program that went into effect in January. Under that program, as it turns out, the prices paid by insurers, and eventually the taxpayer, for the medications given to those transferred are likely to be higher than what was paid under the federal-state Medicaid programs for the poor.
About 6.5 million low-income elderly people or younger disabled poor people were automatically transferred into the Part D program for drug coverage. Because their other health needs are still covered by Medicaid, they are called dual eligibles.
The advent of Part D has not affected the drug coverage for the 45 million other low-income people whose drugs are still paid for under state Medicaid programs. Those programs closely monitor drug prices, and drug makers often typically end up paying rebates to the states.
It is too early to calculate the full effect of the shift of the former Medicaid patients now covered by Part D. But analysts expect it to generate hundreds of millions of additional dollars this year for the drug companies, which have long chafed under the pricing restraints of the state programs.
Drugs tend to be cheaper under the Medicaid programs because the states are the buyers and by law they receive the lowest available prices for drugs.
But in creating the federal Part D program, Congress — in what critics saw as a sop to the drug industry — barred the government from having a negotiating role. Instead, prices are worked out between drug makers and the dozens of large and small Part D drug plans run by commercial insurers.
Since Part D went into effect, the pharmaceutical industry has raised the wholesale prices of its brand-name drugs an average of 3.6 percent. Although the actual amount spent depends on what each insurer negotiates, in many cases the drugs for those 6.5 million people who used to receive their medicines through Medicaid will cost more now.
Initially, the added costs will be paid by the insurers administering the new Medicare drug program. But when it comes time for the insurers to settle accounts with the government, the costs of the 6.5 million drugs for the transferees will end up being passed along to federal taxpayers, according to analysts and health care economists.
The windfall for the drug makers was made possible by a provision of the 2003 Medicare law that exempts Part D drugs from “best price” rebates that the drug makers have been required to give to the state Medicaid programs since 1991. Those rebates are meant to make sure that state Medicaid agencies pay no more than the best prices drug companies offer to any big commercial insurer.
Under Medicaid, the federal government and state agencies paid more than $14 billion annually for the drugs of the 6.5 million transferees. Without the best-price rebates, the cost would have been 25 percent higher, or about $17.5 billion, said Stephen W. Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota.
Nobody yet knows what the total drug bill will be for these people under Part D, beyond the assumption by many experts that it will be higher. Medicare will not have solid numbers until it can analyze the hundreds of monthly reports that the plans in the Part D system are required to file.
Yet, one indicator of the higher revenue from dual-eligibles has already been seen in reports by drug companies this year showing double-digit United States sales increases of certain drugs that are heavily used by Medicaid patients. For example, sales of Lamictal, an antipsychosis drug from GlaxoSmithKline, were up 33 percent, to $305 million in the first quarter; sales of Seroquel, an antipsychotic from AstraZeneca, were up 29 percent, to $590 million; and sales of Plavix, a blood thinner from Bristol-Myers Squibb, were up 26 percent, to $850 million.
Timothy Anderson, a pharmaceutical analyst with the Prudential Equity Group, estimates that if Part D were not in place the rebates for the makers for all of 2006 would have been more than $2 billion for 13 drugs widely used by the people transferred from Medicaid to Part D.
Dr. Anderson estimates that because the companies will not have to pay those rebates under Part D, revenue to Glaxo from Lamictal will increase by $298 million this year, AstraZeneca’s Seroquel sales will rise by $521 million, and Plavix revenue will increase $169 million. Estimates on the rebate increases because of Part D are few, but all are in general agreement on the size of the rebate to drug makers.
Medicaid programs have been especially important for drugs like Seroquel and Lamictal, which are prescribed for bipolar disorder and other mental health problems
About two million of the people transferred to Part D are disabled and younger than 65, and “more than half of them have mental health problems,” said Jim Verdier, a senior fellow at Mathematica Policy Research in Washington and a former Medicaid director in Indiana. “In the past, Medicaid was 80 to 90 percent of the total market for some high-end antipsychotic drugs,” Mr. Verdier said.
Over all, the Medicaid best-price rebates have averaged about 15 percent of the list prices of the manufacturers, but some states, including California, New York and Maine have obtained even larger rebates, Professor Schondelmeyer said.
Now, under Part D, all sorts of price deals will be negotiated by dozens of Medicare drug plans, large and small. The prices will be reported to Medicare, but under a provision of the law pushed by industry lobbyists, they will otherwise be kept secret.
Mark B. McClellan, administrator of the federal agency that oversees Medicare and Medicaid, said that the lowest-cost plans among the Part D offerings by commercial insurers were now getting “significantly better prices than Medicaid.” But he did not provide specifics.
Dr. McClellan also noted that his agency was requiring the states to return a combined total of $5.8 billion to Washington from federal funds dispensed to the Medicaid program. That money is based on a federal estimate of the amount states will be saving by no longer having to provide drugs to the dual-eligibles.
But the states, disparaging those refunds as “clawbacks,’’ have disputed the federal formula that was the basis for the repayments. Last month, the Supreme Court declined to hear a case filed by the attorneys general of Texas and four other states seeking to quash the repayment formula as unconstitutional.
Now the plaintiffs, which also include Kentucky, Maine, Missouri, and New Jersey, are expected to take the fight to lower courts. Ten other states have supported the plaintiffs.
The states say the federal formula assumes higher drug costs than many Medicaid programs have been spending.
“We get 32 percent back in drug rebates,” said Jude E. Walsh, a special assistant to Governor John Baldacci of Maine. She said Maine’s Medicaid drug costs were rising only 2 percent to 3 percent a year, compared with national trends that are three to four times that.
The drug companies, for their part, have played down the size of the expected windfall from Medicaid transferees. And Bush administration officials say they do not know how much they will end up spending on those people. “No one is willing to quantify it,” said Dr. Anderson, the Prudential analyst.
In one of the few public comments by a drug company official, Derica W. Rice, chief financial officer of Eli Lilly, told analysts on a conference call in April that Lilly expected “modest price benefits due to lower rebates as patients move from Medicaid to Plan D.”
Zyprexa, a Lilly drug for schizophrenia, is another medication widely prescribed for Medicaid patients.
The drug makers do have reason to worry about long-run prospects under the vast new Medicare Part D program. There are currently 81 Part D drug plan sponsors, large and small, with varying degrees of negotiating power. But the plans are expected eventually to merge into a handful of large survivors, each of them presumably having more bargaining power with drug companies.
A further concern is that as the true costs of Part D become known, Congress may eventually impose spending ceilings.
For now though, as the drug industry begins to report its quarterly profits, the market for those 6.5 million poor people is likely to look rather
Change Healthcare in the US
A recent article in the Wall Street Journal called for an overhaul of the US healthcare system. The author called for a move from an employer-based health care system to a universal system. The author states that "To fix health care in America, we have to accept that we're living through the most profound transformative economic revolution in the history of the world. It's happening so fast we can barely keep track of it. Intense global competition. Contingent work. The explosive economies of China and India. Technology in the workplace. Outsourcing. By the time they are 35, young people entering the job market today will already have worked in eight to 12 jobs. Employers will be pit stops for them, not permanent homes. In other words, we are rapidly moving from employer-managed work lives to self-managed work lives, in which workers must figure out on their own how to maintain things like health insurance and retirement." His analysis is correct, but his conclusion to establish a universal health care system may not be accepted by everyone. This probably would be just another article dealing with our healthcare mess, if not for the author: Andy Stern, is the President of the Service Employees International Union, comprised of one million nurses, doctors, hospital staff, nursing home and home care workers. We should listen to him and I think organized medicine should engage him in a discussion how to find solutions for our broken healthcare system.As a former union leader and organizer I strongly support such a cooperation.
Horse-and-Buggy Health Coverage
By ANDY STERN
WSJ, July 17, 2006; Page A10
There is no subject that gets more discussion, analysis and lament than health care in America. Enough already. It's time to assert one simple fact: The employer-based system of health coverage is over. This may sound shocking, coming from a union leader whose members bargain constantly with employers for health-care benefits. But the system is collapsing, crushed by out-of-control costs, a revolutionary global economy and masses of uninsured.
CEOs know this best: They dread the meeting with HR managers who tell them, once again, that their health-care costs are through the roof. So they look for any way to control costs. Co-pays go up, subsidies go down, coverage is dropped all together. In the last five years alone, the percentage of businesses offering health benefits has plummeted to 60% from 69%. Here's how bad it will continue to get: McKinsey & Company projects that by 2008, the average Fortune 500 company will spend as much on health care as they make in profit. How can we possibly compete in the global economy with that kind of burden?
I understand why CEOs are afraid of health-care costs. What I don't understand is why they are so timid about doing something about them. These are the people who revolutionized medicine, communication, technology, entertainment and investing. And yet when it comes to addressing the biggest economic issue their companies and their country face, they resort to bookkeeping. Where are the visionaries? The tough-minded magnates who make billions for shareholders? Stuck in the 20th century, that's where.
To fix health care in America, we have to accept that we're living through the most profound transformative economic revolution in the history of the world. It's happening so fast we can barely keep track of it. Intense global competition. Contingent work. The explosive economies of China and India. Technology in the workplace. Outsourcing. By the time they are 35, young people entering the job market today will already have worked in eight to 12 jobs. Employers will be pit stops for them, not permanent homes. In other words, we are rapidly moving from employer-managed work lives to self-managed work lives, in which workers must figure out on their own how to maintain things like health insurance and retirement.
A new national policy framework is the easy part. There seems to be broad consensus that we need a universal system that provides affordable coverage, choice of doctors and insurance plans, core benefits, and shared financing among employers, employees and government. There are a couple of thousand position papers out there to choose from. The problem isn't policy, it's leadership. And I don't mean Washington, D.C. The political class in both parties is full of words and bereft of action. They are not going to provide the answers until they are forced to. That force must come from the business community.
Today I sent a letter to every CEO in the Fortune 500 asking them to make health care their national priority. I urge corporate leaders to come forward. Our union members -- your employees -- will work with you. The old idea that business and labor can't work together for the common good is as outdated as lifetime jobs. The Service Employees International Union is the largest health-care union in the country. Our membership includes nearly one million nurses, doctors, hospital staff, nursing home and home care workers. We know health care. You know business. Together, let's build a new 21st-century American economy.
Mr. Stern, president of the Service Employees International Union, is author of "A Country That Works," forthcoming from Free Press.
Horse-and-Buggy Health Coverage
By ANDY STERN
WSJ, July 17, 2006; Page A10
There is no subject that gets more discussion, analysis and lament than health care in America. Enough already. It's time to assert one simple fact: The employer-based system of health coverage is over. This may sound shocking, coming from a union leader whose members bargain constantly with employers for health-care benefits. But the system is collapsing, crushed by out-of-control costs, a revolutionary global economy and masses of uninsured.
CEOs know this best: They dread the meeting with HR managers who tell them, once again, that their health-care costs are through the roof. So they look for any way to control costs. Co-pays go up, subsidies go down, coverage is dropped all together. In the last five years alone, the percentage of businesses offering health benefits has plummeted to 60% from 69%. Here's how bad it will continue to get: McKinsey & Company projects that by 2008, the average Fortune 500 company will spend as much on health care as they make in profit. How can we possibly compete in the global economy with that kind of burden?
I understand why CEOs are afraid of health-care costs. What I don't understand is why they are so timid about doing something about them. These are the people who revolutionized medicine, communication, technology, entertainment and investing. And yet when it comes to addressing the biggest economic issue their companies and their country face, they resort to bookkeeping. Where are the visionaries? The tough-minded magnates who make billions for shareholders? Stuck in the 20th century, that's where.
To fix health care in America, we have to accept that we're living through the most profound transformative economic revolution in the history of the world. It's happening so fast we can barely keep track of it. Intense global competition. Contingent work. The explosive economies of China and India. Technology in the workplace. Outsourcing. By the time they are 35, young people entering the job market today will already have worked in eight to 12 jobs. Employers will be pit stops for them, not permanent homes. In other words, we are rapidly moving from employer-managed work lives to self-managed work lives, in which workers must figure out on their own how to maintain things like health insurance and retirement.
A new national policy framework is the easy part. There seems to be broad consensus that we need a universal system that provides affordable coverage, choice of doctors and insurance plans, core benefits, and shared financing among employers, employees and government. There are a couple of thousand position papers out there to choose from. The problem isn't policy, it's leadership. And I don't mean Washington, D.C. The political class in both parties is full of words and bereft of action. They are not going to provide the answers until they are forced to. That force must come from the business community.
Today I sent a letter to every CEO in the Fortune 500 asking them to make health care their national priority. I urge corporate leaders to come forward. Our union members -- your employees -- will work with you. The old idea that business and labor can't work together for the common good is as outdated as lifetime jobs. The Service Employees International Union is the largest health-care union in the country. Our membership includes nearly one million nurses, doctors, hospital staff, nursing home and home care workers. We know health care. You know business. Together, let's build a new 21st-century American economy.
Mr. Stern, president of the Service Employees International Union, is author of "A Country That Works," forthcoming from Free Press.
IOM Report: Medication Errors
New IOM Report highlights the increasing incidence of medication errors.Medication errors harm 1.5 million people and kill several thousand each year in the United States, costing the nation at least $3.5 billion annually, the Institute of Medicine concluded in a new report see http://www.iom.edu/CMS/3809/22526/35939.aspx Recommendations to correct these problems include systemic changes like electronic prescribing and tips for consumers like advising patients to carry complete listings of their prescriptions to every doctor’s visit, the report said. As physicians we should proactively undertake every reasonable effort to reduce the incidence of medication errors. I use electronic prescribing for several years and have caught multiple errors related to drug-interactions, wrong dosage and limited legibility issues.
Institute Cites Medication Errors,
Suggests Changes to Cut Injuries
By SHIRLEY S. WANG
WSJ July 21, 2006; Page A11
Medication errors serious enough to cause injury occur 1.5 million times a year in the U.S., according to a report released by the Institute of Medicine of the National Academies.
The report makes ambitious recommendations for reducing the rate of errors, with U.S. agencies taking the lead, and recommends deadlines. It calls for $100 million in research to determine the best and most cost-effective measures.
A previous report from the IOM, which in 1999 estimated that medical errors of all types were responsible for as many as 98,000 deaths a year, spurred the government to pour $50 million into patient-safety initiatives and invigorated efforts among health-care providers and insurers to reduce errors. Hospitals are working on a number of initiatives, including the use of electronic order-entry systems.
The report recommends that all health-care providers use an electronic system to prescribe drugs by 2010. "Large hospitals are pretty much invested in moving in that direction," J. Lyle Bootman, dean at the University of Arizona College of Pharmacy said, though other medical settings, such as long-term-care facilities, may need more help with implementation. Dr. Bootman was co-chairman of the Committee on Identifying and Preventing Medication Errors, which drafted the IOM report.
The report also found that confusing drug labels and packaging are responsible for one-quarter to one-third of medication errors, including 30% of all medication-error deaths. The report urged the Food and Drug Administration and the federal Agency for Healthcare Research and Quality to work with industry to address problems by the end of 2007 and possibly standardize drug names and labels.
The report recommended that the National Library of Medicine create a centralized online database on drugs to help consumers. The NLM should also spearhead an initiative with the FDA and Centers for Medicare and Medicaid Services to consider a nationwide telephone hot line for people who can't read printed materials.
July 21, 2006
Report Finds a Heavy Toll From Medication Errors
By GARDINER HARRIS
WASHINGTON, NYT July 20 — Medication errors harm 1.5 million people and kill several thousand each year in the United States, costing the nation at least $3.5 billion annually, the Institute of Medicine concluded in a report released on Thursday.
Drug errors are so widespread that hospital patients should expect to suffer one every day they remain hospitalized, although error rates vary by hospital and most do not lead to injury, the report concluded.
The report, “Preventing Medication Errors,” cited the death of Betsy Lehman, a 39-year-old mother of two and a health reporter for The Boston Globe, as a classic fatal drug mix-up. Ms. Lehman died in 1993 after a doctor mistakenly gave her four times the appropriate dose of a toxic drug to treat her breast cancer.
Recommendations to correct these problems include systemic changes like electronic prescribing and tips for consumers like advising patients to carry complete listings of their prescriptions to every doctor’s visit, the report said.
“The incidence of medication errors was surprising even to us,” said J. Lyle Bootman, dean of the University of Arizona College of Pharmacy. “The solutions are complex and far-reaching and will present challenges.”
The report is the fourth in a series done by the institute, the nation’s most prestigious medical advisory organization, that has called attention to the enormous health and financial burdens brought about by medical errors.
The first report, “To Err Is Human,” was released in 1999 and caused a sensation when it estimated that medical errors of all sorts led to as many as 98,000 deaths each year — more than was caused by highway accidents and breast cancer combined.
After the first report, health officials and hospital groups pledged reforms, but many of the most important efforts have been slow to take hold.
Drug computer-entry systems, which are supposed to ensure that hospital patients get the right drugs at the right dose, are used in just 6 percent of the nation’s hospitals, said Charles B. Inlander, president of the People’s Medical Society, a consumer advocacy group, and an author of the report released Thursday.
Electronic medical records can help ensure that patients do not receive toxic drug combinations. The 1999 report urged widespread adoption of these systems. Thursday’s report called for all prescriptions to be written electronically by 2010.
Just 3 percent of hospitals have electronic patient records, said Henri Manasse, chief executive of the American Society of Health-System Pharmacists. Few doctors prescribe drugs electronically.
Even simple medication safety recommendations — block printing on hand-written prescription forms — are widely ignored.
Arthur Levin, director of the Center for Medical Consumers and an author of the 1999 report, said that just about everyone in the health system was to blame. “This country has not taken seriously the alarms we sounded in 1999,” Mr. Levin said. “Why?”
Health organizations defended their efforts.
Alicia Mitchell, a spokeswoman for the American Hospital Association, said that since 1999 hospitals had “actively engaged in looking at using information technology to improve patient safety.”
A recent poll by the association of its members found that 92 percent intended to adopt electronic patient records, Ms. Mitchell said. But such systems are complicated and need to be built gradually, she said.
Thursday’s report urged the Food and Drug Administration to improve and standardize the drug information leaflets given consumers. It noted that confusing information on drug labels was an important cause of medication errors.
On Tuesday, the drug agency finished a years-long process by issuing voluntary guidelines to reform consumer drug information leaflets, said Dr. Scott Gottlieb, the agency’s deputy commissioner. Many of these leaflets are not regulated by the F.D.A.
And on June 30, the agency completed a lengthy effort to clarify and standardize information on drug labels. The new labels could prevent nearly 300,000 medication errors each year and will make electronic prescribing efforts far easier to carry out, Dr. Gottlieb said.
Thursday’s report said that the common practice whereby drug companies provided free drug samples to doctors should be discouraged because such samples were poorly controlled. It urged drug makers to package more pills in individual packages. And it criticized drug makers as failing to disclose the results of all clinical trials involving their drugs.
Alan Goldhammer, a spokesman for the Pharmaceutical Research and Manufacturers of America, a drug industry trade group, said he differed with some of the report’s conclusions but concurred with the broad goals of increasing the use of information technology to reduce medication errors.
“Everybody is working on that right now,” he said.
Thursday’s report said that in any given week, four out of five adults in the United States took at least one medication. A third take at least five different medications. As the use of medications has soared, so, too have medication errors, Dr. Manasse said.
Effective strategies to prevent such errors have, however, been known for years, Mr. Inlander said.
“This is not rocket science,” Mr. Inlander said. “It’s simple. The key is having the will to make these changes in an organized and uniform way. And it’s not that expensive.”
Institute Cites Medication Errors,
Suggests Changes to Cut Injuries
By SHIRLEY S. WANG
WSJ July 21, 2006; Page A11
Medication errors serious enough to cause injury occur 1.5 million times a year in the U.S., according to a report released by the Institute of Medicine of the National Academies.
The report makes ambitious recommendations for reducing the rate of errors, with U.S. agencies taking the lead, and recommends deadlines. It calls for $100 million in research to determine the best and most cost-effective measures.
A previous report from the IOM, which in 1999 estimated that medical errors of all types were responsible for as many as 98,000 deaths a year, spurred the government to pour $50 million into patient-safety initiatives and invigorated efforts among health-care providers and insurers to reduce errors. Hospitals are working on a number of initiatives, including the use of electronic order-entry systems.
The report recommends that all health-care providers use an electronic system to prescribe drugs by 2010. "Large hospitals are pretty much invested in moving in that direction," J. Lyle Bootman, dean at the University of Arizona College of Pharmacy said, though other medical settings, such as long-term-care facilities, may need more help with implementation. Dr. Bootman was co-chairman of the Committee on Identifying and Preventing Medication Errors, which drafted the IOM report.
The report also found that confusing drug labels and packaging are responsible for one-quarter to one-third of medication errors, including 30% of all medication-error deaths. The report urged the Food and Drug Administration and the federal Agency for Healthcare Research and Quality to work with industry to address problems by the end of 2007 and possibly standardize drug names and labels.
The report recommended that the National Library of Medicine create a centralized online database on drugs to help consumers. The NLM should also spearhead an initiative with the FDA and Centers for Medicare and Medicaid Services to consider a nationwide telephone hot line for people who can't read printed materials.
July 21, 2006
Report Finds a Heavy Toll From Medication Errors
By GARDINER HARRIS
WASHINGTON, NYT July 20 — Medication errors harm 1.5 million people and kill several thousand each year in the United States, costing the nation at least $3.5 billion annually, the Institute of Medicine concluded in a report released on Thursday.
Drug errors are so widespread that hospital patients should expect to suffer one every day they remain hospitalized, although error rates vary by hospital and most do not lead to injury, the report concluded.
The report, “Preventing Medication Errors,” cited the death of Betsy Lehman, a 39-year-old mother of two and a health reporter for The Boston Globe, as a classic fatal drug mix-up. Ms. Lehman died in 1993 after a doctor mistakenly gave her four times the appropriate dose of a toxic drug to treat her breast cancer.
Recommendations to correct these problems include systemic changes like electronic prescribing and tips for consumers like advising patients to carry complete listings of their prescriptions to every doctor’s visit, the report said.
“The incidence of medication errors was surprising even to us,” said J. Lyle Bootman, dean of the University of Arizona College of Pharmacy. “The solutions are complex and far-reaching and will present challenges.”
The report is the fourth in a series done by the institute, the nation’s most prestigious medical advisory organization, that has called attention to the enormous health and financial burdens brought about by medical errors.
The first report, “To Err Is Human,” was released in 1999 and caused a sensation when it estimated that medical errors of all sorts led to as many as 98,000 deaths each year — more than was caused by highway accidents and breast cancer combined.
After the first report, health officials and hospital groups pledged reforms, but many of the most important efforts have been slow to take hold.
Drug computer-entry systems, which are supposed to ensure that hospital patients get the right drugs at the right dose, are used in just 6 percent of the nation’s hospitals, said Charles B. Inlander, president of the People’s Medical Society, a consumer advocacy group, and an author of the report released Thursday.
Electronic medical records can help ensure that patients do not receive toxic drug combinations. The 1999 report urged widespread adoption of these systems. Thursday’s report called for all prescriptions to be written electronically by 2010.
Just 3 percent of hospitals have electronic patient records, said Henri Manasse, chief executive of the American Society of Health-System Pharmacists. Few doctors prescribe drugs electronically.
Even simple medication safety recommendations — block printing on hand-written prescription forms — are widely ignored.
Arthur Levin, director of the Center for Medical Consumers and an author of the 1999 report, said that just about everyone in the health system was to blame. “This country has not taken seriously the alarms we sounded in 1999,” Mr. Levin said. “Why?”
Health organizations defended their efforts.
Alicia Mitchell, a spokeswoman for the American Hospital Association, said that since 1999 hospitals had “actively engaged in looking at using information technology to improve patient safety.”
A recent poll by the association of its members found that 92 percent intended to adopt electronic patient records, Ms. Mitchell said. But such systems are complicated and need to be built gradually, she said.
Thursday’s report urged the Food and Drug Administration to improve and standardize the drug information leaflets given consumers. It noted that confusing information on drug labels was an important cause of medication errors.
On Tuesday, the drug agency finished a years-long process by issuing voluntary guidelines to reform consumer drug information leaflets, said Dr. Scott Gottlieb, the agency’s deputy commissioner. Many of these leaflets are not regulated by the F.D.A.
And on June 30, the agency completed a lengthy effort to clarify and standardize information on drug labels. The new labels could prevent nearly 300,000 medication errors each year and will make electronic prescribing efforts far easier to carry out, Dr. Gottlieb said.
Thursday’s report said that the common practice whereby drug companies provided free drug samples to doctors should be discouraged because such samples were poorly controlled. It urged drug makers to package more pills in individual packages. And it criticized drug makers as failing to disclose the results of all clinical trials involving their drugs.
Alan Goldhammer, a spokesman for the Pharmaceutical Research and Manufacturers of America, a drug industry trade group, said he differed with some of the report’s conclusions but concurred with the broad goals of increasing the use of information technology to reduce medication errors.
“Everybody is working on that right now,” he said.
Thursday’s report said that in any given week, four out of five adults in the United States took at least one medication. A third take at least five different medications. As the use of medications has soared, so, too have medication errors, Dr. Manasse said.
Effective strategies to prevent such errors have, however, been known for years, Mr. Inlander said.
“This is not rocket science,” Mr. Inlander said. “It’s simple. The key is having the will to make these changes in an organized and uniform way. And it’s not that expensive.”
Trial Bar Changes Name
What an ironey. The Trial Bar will change its name to the "American Association of Justice". Nice try. The wolves in sheep clothing are still wolves.
Bernd
Lawyers Anonymous
WSJ July 19, 2006; Page A12
What's in a name? More, it would seem, if the name doesn't contain the words "trial" or "lawyer."
At least that's the hope of the Association of Trial Lawyers of America, which today will ask its membership to vote to give that 60-year-old political lobbying institution a brand new moniker. ATLA's board of governors already resoundingly approved a switch, voting 91-5 last month to drop any reference to the lawyerly profession, and instead go with the impressively unspecific and high-minded "American Association for Justice." No word yet whether Webster's will formally protest.
Driving this switcheroo is ATLA's concern that more and more Americans are under the impression that trial lawyers are less interested in justice than they are in generating frivolous lawsuits that pad their own bank accounts. That widely held belief is what has in recent years propelled states from Texas to Ohio to enact tort reform, Congress to pass a class-action lawsuit cleanup, and voters to toss out elected judges who favor the plaintiffs bar.
All of which has ATLA (er, AAJ) a little bothered. As President Ken Suggs wrote in a recent letter to members, "Our research shows that if our message is about helping lawyers, we lose. On the other hand, if we're about getting justice and holding wrongdoers accountable, we win." As to whether the research also showed that one way to improve the trial bar's reputation is to stop fleecing the innocent, Mr. Suggs did not say. Instead, the group has tripled its communications staff and hired noted pollsters and campaign strategists to recast its image. As the old joke goes, it's 98% of lawyers who give the rest of them a bad name.
Bernd
Lawyers Anonymous
WSJ July 19, 2006; Page A12
What's in a name? More, it would seem, if the name doesn't contain the words "trial" or "lawyer."
At least that's the hope of the Association of Trial Lawyers of America, which today will ask its membership to vote to give that 60-year-old political lobbying institution a brand new moniker. ATLA's board of governors already resoundingly approved a switch, voting 91-5 last month to drop any reference to the lawyerly profession, and instead go with the impressively unspecific and high-minded "American Association for Justice." No word yet whether Webster's will formally protest.
Driving this switcheroo is ATLA's concern that more and more Americans are under the impression that trial lawyers are less interested in justice than they are in generating frivolous lawsuits that pad their own bank accounts. That widely held belief is what has in recent years propelled states from Texas to Ohio to enact tort reform, Congress to pass a class-action lawsuit cleanup, and voters to toss out elected judges who favor the plaintiffs bar.
All of which has ATLA (er, AAJ) a little bothered. As President Ken Suggs wrote in a recent letter to members, "Our research shows that if our message is about helping lawyers, we lose. On the other hand, if we're about getting justice and holding wrongdoers accountable, we win." As to whether the research also showed that one way to improve the trial bar's reputation is to stop fleecing the innocent, Mr. Suggs did not say. Instead, the group has tripled its communications staff and hired noted pollsters and campaign strategists to recast its image. As the old joke goes, it's 98% of lawyers who give the rest of them a bad name.
Wednesday, July 05, 2006
Health Care Costs on the Rise (Again)
Dear Friends and Colleagues:
Attached an article from today's Wall Street Journal.
Some of the findings should be of grave concern for each of us seeking affordable healthcare coverage.
1) The average annual medical cost for a family of four participating in a preferred provider organization, or PPO, program is up 9.6% from 2005 to $13,382 in 2006,
2) Fidelity Investments has estimated that a 65-year-old couple retiring without employer-provided health benefits will need $200,000 for out-of-pocket health-care expenses during retirement.
Guess, I have to be less concerned of a North Korean missile falling in my backyard, than healthcare costs spiraling out of control jeopardizing my families financial future.
Bernd
Health-Care Costs To Hit Workers, Retirees Harder
By JILIAN MINCER
July 5, 2006; Page D3
Americans should expect to pay more for medical costs whether they are employed or retired, according to two new studies. The reports, by Milliman Inc. and Watson Wyatt Worldwide, show that health-care costs are still rising at a fast pace -- despite slowing from double-digit rates in recent years -- and that businesses expect to curtail or limit retiree medical benefits.
"Both of the studies are reverifying the fact that health care is becoming more expensive," says Paul Fronstin, director of health research for the Employee Benefit Research Institute, or EBRI, a nonprofit research group in Washington. "We've seen this trend since the 1990s."
The average annual medical cost for a family of four participating in a preferred provider organization, or PPO, program is up 9.6% from 2005 to $13,382 in 2006, according to Milliman, a consulting and actuarial firm that released its second annual study Thursday. Unlike other major health-care cost studies, which look at costs in terms of annual premiums or just the employer's share, the Milliman study also factors in employees' costs, including out-of-pocket expenses.
A separate study by Watson Wyatt, a global management-consulting firm, found that businesses expect to further restrict or eliminate retiree medical plans.
The Milliman study says that employers are projected to pay about $8,362, or 62%, of the total medical cost for a family of four. The total is $13,382. The employee pays about $5,020, $2,810 in payroll deductions and $2,210 in cost sharing.
The Milliman Index is based on analysis of claim costs for millions of members in a variety of areas of the country.
The Milliman Medical Index also looked at the cost of health care in several major cities over the last year. New York City was the most expensive at $15,255, and Dallas the least expensive at $12,980.
The vast majority of businesses are planning to curtail medical plans for current and future retirees, according to the Watson Wyatt study. The survey of 164 companies found that 14% plan to eliminate the benefit for future retirees over age 65, and 6% plan to eliminate it for their current retirees over age 65.
While most employers who still provide the coverage plan to continue it, retirees should expect to pay more for their coverage. "The good news is that they're all not jumping out. The majority are still going to provide it," says Cara Jareb, director of retiree medical consulting at Watson Wyatt. "The bad news is they will be paying more for this coverage."
Nearly two-thirds of employers expect to increase the financial contribution for future retirees, and half expect to change the design of their plans. Twenty-four percent plan to tighten eligibility for future retirees.
Fidelity Investments has estimated that a 65-year-old couple retiring without employer-provided health benefits will need $200,000 for out-of-pocket health-care expenses during retirement.
Attached an article from today's Wall Street Journal.
Some of the findings should be of grave concern for each of us seeking affordable healthcare coverage.
1) The average annual medical cost for a family of four participating in a preferred provider organization, or PPO, program is up 9.6% from 2005 to $13,382 in 2006,
2) Fidelity Investments has estimated that a 65-year-old couple retiring without employer-provided health benefits will need $200,000 for out-of-pocket health-care expenses during retirement.
Guess, I have to be less concerned of a North Korean missile falling in my backyard, than healthcare costs spiraling out of control jeopardizing my families financial future.
Bernd
Health-Care Costs To Hit Workers, Retirees Harder
By JILIAN MINCER
July 5, 2006; Page D3
Americans should expect to pay more for medical costs whether they are employed or retired, according to two new studies. The reports, by Milliman Inc. and Watson Wyatt Worldwide, show that health-care costs are still rising at a fast pace -- despite slowing from double-digit rates in recent years -- and that businesses expect to curtail or limit retiree medical benefits.
"Both of the studies are reverifying the fact that health care is becoming more expensive," says Paul Fronstin, director of health research for the Employee Benefit Research Institute, or EBRI, a nonprofit research group in Washington. "We've seen this trend since the 1990s."
The average annual medical cost for a family of four participating in a preferred provider organization, or PPO, program is up 9.6% from 2005 to $13,382 in 2006, according to Milliman, a consulting and actuarial firm that released its second annual study Thursday. Unlike other major health-care cost studies, which look at costs in terms of annual premiums or just the employer's share, the Milliman study also factors in employees' costs, including out-of-pocket expenses.
A separate study by Watson Wyatt, a global management-consulting firm, found that businesses expect to further restrict or eliminate retiree medical plans.
The Milliman study says that employers are projected to pay about $8,362, or 62%, of the total medical cost for a family of four. The total is $13,382. The employee pays about $5,020, $2,810 in payroll deductions and $2,210 in cost sharing.
The Milliman Index is based on analysis of claim costs for millions of members in a variety of areas of the country.
The Milliman Medical Index also looked at the cost of health care in several major cities over the last year. New York City was the most expensive at $15,255, and Dallas the least expensive at $12,980.
The vast majority of businesses are planning to curtail medical plans for current and future retirees, according to the Watson Wyatt study. The survey of 164 companies found that 14% plan to eliminate the benefit for future retirees over age 65, and 6% plan to eliminate it for their current retirees over age 65.
While most employers who still provide the coverage plan to continue it, retirees should expect to pay more for their coverage. "The good news is that they're all not jumping out. The majority are still going to provide it," says Cara Jareb, director of retiree medical consulting at Watson Wyatt. "The bad news is they will be paying more for this coverage."
Nearly two-thirds of employers expect to increase the financial contribution for future retirees, and half expect to change the design of their plans. Twenty-four percent plan to tighten eligibility for future retirees.
Fidelity Investments has estimated that a 65-year-old couple retiring without employer-provided health benefits will need $200,000 for out-of-pocket health-care expenses during retirement.
In Store Clinics
LETTER TO THE EDITOR:
RE: Drugstore Diagnosis: No appointment necessary; by Maureen Glabman, Florida Medical Business, June 13-June 26,06:
The AMA House of Delegates emphasized during the Association's Annual Meeting that the in-store clinics are no substitute for a long-term relationship with a trained and board-certified medical doctor. These clinics may provide invaluable medical services for the insured, uninsured and underinsured who value the convenience and flexibility of getting treatment on a walk-in basis instead of having to schedule an appointment to see their physician. Even though the operators of those clinics claim that they do not substitute but complement the existing medical services at doctors offices, the delegates at the AMA Annual Meeting expressed concern about the clinics' impact on quality care, leading the house to adopt nine guidelines and direct the AMA to monitor the effects of the clinics on the health care marketplace.
These guidelines can be sumarized as follows:
* Encourage patients to establish a relationship with a primary care physician to
ensure continuity of care.
* Have a well-defined and limited scope of clinical services consistent with
state scope-of-practice laws.
* Use standardized medical protocols derived from evidence-based practice
guidelines to ensure patient safety and quality of care.
* Establish protocols for ensuring continuity of care with practicing physicians
within a local community.
* Set up a referral system with physician practices or other facilities for
appropriate treatment if the patient's conditions or symptoms are beyond the
scope of services provided by the clinic.
* Clearly inform patients in advance of the qualifications of their health care
practitioners as well as limitations in the types of illnesses that they can
diagnose and treat.
* Establish appropriate sanitation and hygienic guidelines and facilities to
ensure the safety of patients.
As a practicing family physician I cautiously support the establishment of in-store clinics as long as they abide by the above guidelines.
All in-store clinics should develop a working relationship with a local primary care physician to provide continuous medical care for patients diagnosed with chronic diseases requiring longitudinal medical care.
In store medical clinic may cater to consumers seeking quick and focused medical attention, but may also create a "quick-fix" mentality for the treatment of medical problems that require the attention of an experienced medical doctor.
Bernd Wollschlaeger, MD, FAAFp
Vice-President Dade County Medical Association
AMA Delegate
RE: Drugstore Diagnosis: No appointment necessary; by Maureen Glabman, Florida Medical Business, June 13-June 26,06:
The AMA House of Delegates emphasized during the Association's Annual Meeting that the in-store clinics are no substitute for a long-term relationship with a trained and board-certified medical doctor. These clinics may provide invaluable medical services for the insured, uninsured and underinsured who value the convenience and flexibility of getting treatment on a walk-in basis instead of having to schedule an appointment to see their physician. Even though the operators of those clinics claim that they do not substitute but complement the existing medical services at doctors offices, the delegates at the AMA Annual Meeting expressed concern about the clinics' impact on quality care, leading the house to adopt nine guidelines and direct the AMA to monitor the effects of the clinics on the health care marketplace.
These guidelines can be sumarized as follows:
* Encourage patients to establish a relationship with a primary care physician to
ensure continuity of care.
* Have a well-defined and limited scope of clinical services consistent with
state scope-of-practice laws.
* Use standardized medical protocols derived from evidence-based practice
guidelines to ensure patient safety and quality of care.
* Establish protocols for ensuring continuity of care with practicing physicians
within a local community.
* Set up a referral system with physician practices or other facilities for
appropriate treatment if the patient's conditions or symptoms are beyond the
scope of services provided by the clinic.
* Clearly inform patients in advance of the qualifications of their health care
practitioners as well as limitations in the types of illnesses that they can
diagnose and treat.
* Establish appropriate sanitation and hygienic guidelines and facilities to
ensure the safety of patients.
As a practicing family physician I cautiously support the establishment of in-store clinics as long as they abide by the above guidelines.
All in-store clinics should develop a working relationship with a local primary care physician to provide continuous medical care for patients diagnosed with chronic diseases requiring longitudinal medical care.
In store medical clinic may cater to consumers seeking quick and focused medical attention, but may also create a "quick-fix" mentality for the treatment of medical problems that require the attention of an experienced medical doctor.
Bernd Wollschlaeger, MD, FAAFp
Vice-President Dade County Medical Association
AMA Delegate
Sunday, July 02, 2006
Save 100,000 Lives Warrant a Second Opinion
Dear Friends and Colleagues:
Attached an article from a recent Wall Street Journal edition discussing the “ Save 100,000 lives” campaign initiated by Prof.Donald Berwick Hospitals participating in the effort had saved 122,300 lives, exceeding expectations. Much of the favorable press coverage mentioned that this was comparable with the estimated 44,000 to 98,000 lives lost each year to medical errors in hospitals.
By the 18-month mark of the campaign, more than 3,000 hospitals were participating, representing about three-quarters of all the nation's hospital beds. Most of these hospitals reported to the Institute for Healthcare Improvement (IHI) the number of admissions and deaths during the campaign period and in 2004 -- the group says information it received was about 86% complete.A simple comparison of the death rates before and during the campaign showed that roughly 33,000 fewer patients died in participating hospitals than would have been expected, based on the year-earlier results. IHI researchers admitted that campaign's effect won't be understood fully until the group can compare its hospitals with others that didn't participate, and compare the results with hospitals' death-rate trends before the campaign began. The group plans to gather those numbers in the next six months and include them in a paper to be submitted to a peer-reviewed journal.
Meanwhile, the numbers have been published in the mainstream media WITHOUT having undergone a stringent peer-review process. This definitely has created false expectations and impressions about the quality of care rendered at US hospitals.
The author correctly states that “ Both the recent study and the 1999 medical-errors analysis raise the question: Are all deaths equal? Both counted each life lost or saved the same way. A patient who has a terminal illness, who will die next week, but would have died this week because of medical error, counts as a life saved. So does the life of a child saved from medical error who is discharged from the hospital in good health.
Yours
Bernd Wollschlaeger,MD
PS: you can also find a list of recent e-mails and their content on my blog http://floridadocs.blogspot.com
Studies on Medical Errors Warrant a Second Opinion June 29, 2006
In December 2004, Harvard professor Donald Berwick launched an ambitious effort aimed at improving U.S. hospitals. His goal was to save 100,000 lives in the next 18 months by convincing hospitals to take steps to cut down on errors and improve care.
Two weeks ago, a group led by Dr. Berwick announced the results to great fanfare: Hospitals participating in the effort had saved 122,300 lives, exceeding expectations. Much of the favorable press coverage mentioned that this was comparable with the estimated 44,000 to 98,000 lives lost each year to medical errors in hospitals.
But such estimates have an inherent drawback: It is difficult, in many cases, to connect whether a patient dies to a single medical error or procedure. Dr. Berwick's group compared death rates during the study with those before the study, but there's no way to know that the improvements came from the group's campaign and not other factors. Also, the group relied on self-reported numbers from hospitals. It's possible that only hospitals with positive outcomes shared information.
Questioning the Numbers
Several of Dr. Berwick's colleagues told me they admire his goals but question his number. "I have no doubt the campaign was a good thing and saved a lot of lives," said Robert Wachter, a professor in the department of medicine at the University of California, San Francisco, and the author of a book about medical errors. "I don't think it saved 122,300." He added that, like in a political campaign, the health-care campaign used "statistics selectively to try to mobilize your base to do good. It's understandable. It's not good science."
H. Gilbert Welch, senior research associate with the Department of Veteran Affairs in White River Junction, Vt., and a critic1 of medical-error estimates, said, "I think there's been a tendency in the errors business to first overstate the size of the problem, and now, I'm afraid, to overstate the effect of interventions on the other side."
The study received broad press coverage, with many accounts headlining the 122,300 number. U.S. News & World Report's headline read2, "122,000 Who Lived." An Associated Press report on the study was published in several newspapers, including The Wall Street Journal3.
The Institute for Healthcare Improvement4, the group behind the study, promised hospitals it wouldn't release the data they provided. However, it offered a customizable press release5 for those that wished to trumpet their results, and several newspaper reports (such as those in the Toledo Blade6 and the Fresno Bee7) included anecdotes and quotes supplied by nearby participating hospitals.
The IHI press release8 was careful to say only that hospitals in the campaign saved 122,300 lives, and Dr. Berwick, who serves as IHI's president and chief executive, told me "it would be stupid" to say the group's campaign was solely responsible. "We think we added to it," he said. IHI is a Boston-based nonprofit organization aimed at improving health care. Its funding comes from charitable foundations and hospitals.
Other Factors
Many hospitals had already undertaken their own efforts to boost the quality of care, prodded by groups such as the Centers for Disease Control and Prevention. But many of the news articles simply stated that the campaign saved all those lives, without qualification. (Numbers Guy readers Dean Anderson, Kirk Jeffrey and Curtis L. Russell spotted some of these articles and suggested I look at this number.)
The IHI initiative called on hospitals to institute six steps9. While one of the steps was aimed at reducing mistakes in administering drugs, the rest appear to focus less on errors and more broadly on improving care: Hospitals were encouraged to take additional steps to prevent infections, for instance. (Not all participating hospitals followed all of the recommended steps.)
By the 18-month mark of the campaign, more than 3,000 hospitals were participating, representing about three-quarters of all the nation's hospital beds. Most of these hospitals reported to IHI the number of admissions and deaths during the campaign period and in 2004 -- the group says information it received was about 86% complete.
IHI filled in the numbers for the rest by extrapolating, a step criticized by Dr. Wachter, who said that those hospitals with the best results may have been more likely to report. "It would be like going to your high-school reunion and extrapolating from the divorce rate and waist line [of those who show up] that everyone is married and stays thin," he said.
A simple comparison of the death rates before and during the campaign showed that roughly 33,000 fewer patients died in participating hospitals than would have been expected, based on the year-earlier results. But that calculation was flawed, Dr. Berwick argued, because the mix of patients changes -- you wouldn't compare mortality among 10 heart-attack victims and 10 sufferers of the flu.
So the group tried to come up with a number that would capture how much sicker patients were during the study than the year earlier. It relied on estimates from three companies that have access to a wide range of data from hospitals, including information on patients' diagnoses and their ages. Partly because the population is aging, those companies all reported that patients are, on average, arriving at hospitals in worse condition than they had in previous years. Based on the data, the group adjusted its estimate upward to 122,300. (IHI explains its methods in a document10 on its Web site.)
Andy Hackbarth, an IHI senior engineer who helped crunch the numbers, said the campaign's effect won't be understood fully until the group can compare its hospitals with others that didn't participate, and compare the results with hospitals' death-rate trends before the campaign began. The group plans to gather those numbers in the next six months and include them in a paper to be submitted to a peer-reviewed journal, Mr. Hackbarth told me.
A Personal Connection
Dr. Berwick found himself at the center of the quality-of-care issue following the hospitalization of his wife, Ann, in 1999. She waited 60 hours for treatment while gravely ill, and three times was left alone on a gurney, though she did eventually recover and leave the hospital. He was the subject of a front-page article11 in the Journal in 2002.
When he launched the campaign in 2004, Dr. Berwick said he was losing patience with the health-care system's halting efforts to respond to a 1999 estimate of deaths due to medical error. That study, from the Institute of Medicine, a National Academy of Sciences group that advises Congress on health, found that 44,000 to 98,000 people die each year because of medical errors. Those numbers remain frequently quoted to this day, even though the numbers are based in part on the experiences of hospital patients 22 years ago.
Much of the public's outraged reaction to the Institute of Medicine report focused on rare, terrifying cases such as botched surgeries or gross misdiagnoses. In an episode of her talk show, Oprah Winfrey asked about 260 members of her studio audience to stand up, and told them that, by a "conservative estimate ... this is the number of people who die every day in hospitals from medical mistakes." Then, her show featured one guest who was misdiagnosed with cancer and underwent a hysterectomy and six months of chemotherapy. Another guest's breasts were removed after she was falsely diagnosed with cancer because of a paperwork mix-up.
But critics of the study pointed out that many of the errors were less blatant. The estimates were based on reviews of hospital discharges in three states -- New York in 1984 and Colorado and Utah in 1992 -- looking for any "adverse events" caused by treatment, and not the underlying condition being treated. But not all adverse events are preventable. For example, if a drug deemed necessary causes dangerous side effects in 1% of patients, it's not known which 1% will suffer. For those who do, that's unquestionably an adverse event, but it may not have been a medical error -- it's certainly less clear-cut than having the wrong leg removed in surgery. (The study tried to estimate which adverse events were preventable, but had difficulty establishing clear cause-and-effect relationships.)
Dr. Berwick told me he considers the Institute of Medicine study "as good a quantitative estimate as we've got," adding, "the point is that [errors] are very large causes of morbidity." (Some estimates have put the figure higher than 98,000. Health Grades Inc., which maintains a Web site12 that measures hospitals based on mortality and complication rates, counted13 195,000 deaths annually between 2000 and 2002.)
Both the recent study and the 1999 medical-errors analysis raise the question: Are all deaths equal? Both counted each life lost or saved the same way. "A patient who has a terminal illness, who will die next week, but would have died this week because of medical error, counts as a life saved," Dr. Berwick told me. So does the life of a child saved from medical error who is discharged from the hospital in good health.
Harold C. Sox, Jr., editor of the Annals of Internal Medicine in Philadelphia, told me that averting deaths is, of course, a good goal, but there are other improvements to care worth pursuing. "Another target could be trying to improve the quality of death, for people for whom death is inevitable, and, as much as possible, to match where death actually occurs with what the patient desires," he said.
Although Dr. Wachter remains critical of the lived-saved estimate trumpeted by Dr. Berwick's group, he told me that he believes even questionable numbers can galvanize the public for the improvement of health care. "There will always be tension between good science and the laudable goal of [Dr. Berwick] and others to move the calcified health-care system forward," he said.
* * *
Attached an article from a recent Wall Street Journal edition discussing the “ Save 100,000 lives” campaign initiated by Prof.Donald Berwick Hospitals participating in the effort had saved 122,300 lives, exceeding expectations. Much of the favorable press coverage mentioned that this was comparable with the estimated 44,000 to 98,000 lives lost each year to medical errors in hospitals.
By the 18-month mark of the campaign, more than 3,000 hospitals were participating, representing about three-quarters of all the nation's hospital beds. Most of these hospitals reported to the Institute for Healthcare Improvement (IHI) the number of admissions and deaths during the campaign period and in 2004 -- the group says information it received was about 86% complete.A simple comparison of the death rates before and during the campaign showed that roughly 33,000 fewer patients died in participating hospitals than would have been expected, based on the year-earlier results. IHI researchers admitted that campaign's effect won't be understood fully until the group can compare its hospitals with others that didn't participate, and compare the results with hospitals' death-rate trends before the campaign began. The group plans to gather those numbers in the next six months and include them in a paper to be submitted to a peer-reviewed journal.
Meanwhile, the numbers have been published in the mainstream media WITHOUT having undergone a stringent peer-review process. This definitely has created false expectations and impressions about the quality of care rendered at US hospitals.
The author correctly states that “ Both the recent study and the 1999 medical-errors analysis raise the question: Are all deaths equal? Both counted each life lost or saved the same way. A patient who has a terminal illness, who will die next week, but would have died this week because of medical error, counts as a life saved. So does the life of a child saved from medical error who is discharged from the hospital in good health.
Yours
Bernd Wollschlaeger,MD
PS: you can also find a list of recent e-mails and their content on my blog http://floridadocs.blogspot.com
Studies on Medical Errors Warrant a Second Opinion June 29, 2006
In December 2004, Harvard professor Donald Berwick launched an ambitious effort aimed at improving U.S. hospitals. His goal was to save 100,000 lives in the next 18 months by convincing hospitals to take steps to cut down on errors and improve care.
Two weeks ago, a group led by Dr. Berwick announced the results to great fanfare: Hospitals participating in the effort had saved 122,300 lives, exceeding expectations. Much of the favorable press coverage mentioned that this was comparable with the estimated 44,000 to 98,000 lives lost each year to medical errors in hospitals.
But such estimates have an inherent drawback: It is difficult, in many cases, to connect whether a patient dies to a single medical error or procedure. Dr. Berwick's group compared death rates during the study with those before the study, but there's no way to know that the improvements came from the group's campaign and not other factors. Also, the group relied on self-reported numbers from hospitals. It's possible that only hospitals with positive outcomes shared information.
Questioning the Numbers
Several of Dr. Berwick's colleagues told me they admire his goals but question his number. "I have no doubt the campaign was a good thing and saved a lot of lives," said Robert Wachter, a professor in the department of medicine at the University of California, San Francisco, and the author of a book about medical errors. "I don't think it saved 122,300." He added that, like in a political campaign, the health-care campaign used "statistics selectively to try to mobilize your base to do good. It's understandable. It's not good science."
H. Gilbert Welch, senior research associate with the Department of Veteran Affairs in White River Junction, Vt., and a critic1 of medical-error estimates, said, "I think there's been a tendency in the errors business to first overstate the size of the problem, and now, I'm afraid, to overstate the effect of interventions on the other side."
The study received broad press coverage, with many accounts headlining the 122,300 number. U.S. News & World Report's headline read2, "122,000 Who Lived." An Associated Press report on the study was published in several newspapers, including The Wall Street Journal3.
The Institute for Healthcare Improvement4, the group behind the study, promised hospitals it wouldn't release the data they provided. However, it offered a customizable press release5 for those that wished to trumpet their results, and several newspaper reports (such as those in the Toledo Blade6 and the Fresno Bee7) included anecdotes and quotes supplied by nearby participating hospitals.
The IHI press release8 was careful to say only that hospitals in the campaign saved 122,300 lives, and Dr. Berwick, who serves as IHI's president and chief executive, told me "it would be stupid" to say the group's campaign was solely responsible. "We think we added to it," he said. IHI is a Boston-based nonprofit organization aimed at improving health care. Its funding comes from charitable foundations and hospitals.
Other Factors
Many hospitals had already undertaken their own efforts to boost the quality of care, prodded by groups such as the Centers for Disease Control and Prevention. But many of the news articles simply stated that the campaign saved all those lives, without qualification. (Numbers Guy readers Dean Anderson, Kirk Jeffrey and Curtis L. Russell spotted some of these articles and suggested I look at this number.)
The IHI initiative called on hospitals to institute six steps9. While one of the steps was aimed at reducing mistakes in administering drugs, the rest appear to focus less on errors and more broadly on improving care: Hospitals were encouraged to take additional steps to prevent infections, for instance. (Not all participating hospitals followed all of the recommended steps.)
By the 18-month mark of the campaign, more than 3,000 hospitals were participating, representing about three-quarters of all the nation's hospital beds. Most of these hospitals reported to IHI the number of admissions and deaths during the campaign period and in 2004 -- the group says information it received was about 86% complete.
IHI filled in the numbers for the rest by extrapolating, a step criticized by Dr. Wachter, who said that those hospitals with the best results may have been more likely to report. "It would be like going to your high-school reunion and extrapolating from the divorce rate and waist line [of those who show up] that everyone is married and stays thin," he said.
A simple comparison of the death rates before and during the campaign showed that roughly 33,000 fewer patients died in participating hospitals than would have been expected, based on the year-earlier results. But that calculation was flawed, Dr. Berwick argued, because the mix of patients changes -- you wouldn't compare mortality among 10 heart-attack victims and 10 sufferers of the flu.
So the group tried to come up with a number that would capture how much sicker patients were during the study than the year earlier. It relied on estimates from three companies that have access to a wide range of data from hospitals, including information on patients' diagnoses and their ages. Partly because the population is aging, those companies all reported that patients are, on average, arriving at hospitals in worse condition than they had in previous years. Based on the data, the group adjusted its estimate upward to 122,300. (IHI explains its methods in a document10 on its Web site.)
Andy Hackbarth, an IHI senior engineer who helped crunch the numbers, said the campaign's effect won't be understood fully until the group can compare its hospitals with others that didn't participate, and compare the results with hospitals' death-rate trends before the campaign began. The group plans to gather those numbers in the next six months and include them in a paper to be submitted to a peer-reviewed journal, Mr. Hackbarth told me.
A Personal Connection
Dr. Berwick found himself at the center of the quality-of-care issue following the hospitalization of his wife, Ann, in 1999. She waited 60 hours for treatment while gravely ill, and three times was left alone on a gurney, though she did eventually recover and leave the hospital. He was the subject of a front-page article11 in the Journal in 2002.
When he launched the campaign in 2004, Dr. Berwick said he was losing patience with the health-care system's halting efforts to respond to a 1999 estimate of deaths due to medical error. That study, from the Institute of Medicine, a National Academy of Sciences group that advises Congress on health, found that 44,000 to 98,000 people die each year because of medical errors. Those numbers remain frequently quoted to this day, even though the numbers are based in part on the experiences of hospital patients 22 years ago.
Much of the public's outraged reaction to the Institute of Medicine report focused on rare, terrifying cases such as botched surgeries or gross misdiagnoses. In an episode of her talk show, Oprah Winfrey asked about 260 members of her studio audience to stand up, and told them that, by a "conservative estimate ... this is the number of people who die every day in hospitals from medical mistakes." Then, her show featured one guest who was misdiagnosed with cancer and underwent a hysterectomy and six months of chemotherapy. Another guest's breasts were removed after she was falsely diagnosed with cancer because of a paperwork mix-up.
But critics of the study pointed out that many of the errors were less blatant. The estimates were based on reviews of hospital discharges in three states -- New York in 1984 and Colorado and Utah in 1992 -- looking for any "adverse events" caused by treatment, and not the underlying condition being treated. But not all adverse events are preventable. For example, if a drug deemed necessary causes dangerous side effects in 1% of patients, it's not known which 1% will suffer. For those who do, that's unquestionably an adverse event, but it may not have been a medical error -- it's certainly less clear-cut than having the wrong leg removed in surgery. (The study tried to estimate which adverse events were preventable, but had difficulty establishing clear cause-and-effect relationships.)
Dr. Berwick told me he considers the Institute of Medicine study "as good a quantitative estimate as we've got," adding, "the point is that [errors] are very large causes of morbidity." (Some estimates have put the figure higher than 98,000. Health Grades Inc., which maintains a Web site12 that measures hospitals based on mortality and complication rates, counted13 195,000 deaths annually between 2000 and 2002.)
Both the recent study and the 1999 medical-errors analysis raise the question: Are all deaths equal? Both counted each life lost or saved the same way. "A patient who has a terminal illness, who will die next week, but would have died this week because of medical error, counts as a life saved," Dr. Berwick told me. So does the life of a child saved from medical error who is discharged from the hospital in good health.
Harold C. Sox, Jr., editor of the Annals of Internal Medicine in Philadelphia, told me that averting deaths is, of course, a good goal, but there are other improvements to care worth pursuing. "Another target could be trying to improve the quality of death, for people for whom death is inevitable, and, as much as possible, to match where death actually occurs with what the patient desires," he said.
Although Dr. Wachter remains critical of the lived-saved estimate trumpeted by Dr. Berwick's group, he told me that he believes even questionable numbers can galvanize the public for the improvement of health care. "There will always be tension between good science and the laudable goal of [Dr. Berwick] and others to move the calcified health-care system forward," he said.
* * *
Medical Errors and Structured Communication
Dear Friends and Colleagues:
Attached an article from a recent Wall Street Journal edition discussing the efforts to reduce the medical error incident rate related to communication errors.
The article describes how several hospitals are developing "structured communication" models to aloow for the seamless transfer of patients from shift to shift.
This is especially important in the context of residency work hour limitations necessitating more frequent patient transfers, which may be associated with a higher error rate unless structured communication models are being followed.
Yours
Bernd Wollschlaeger,MD
PS: you can also find a list of recent e-mails and their content on my blog http://floridadocs.blogspot.com
Hospitals Combat Errors at the 'Hand-Off'- New Procedures Aim to Reduce Miscues as Nurses and Doctors Transfer Patients to Next Shift
June 28, 2006; Page D1
For hospitals, the "hand-off" has long been the Bermuda Triangle of health care: Dangerous errors and oversights can occur in the gap when a patient is moved to another unit or turned over to a new nurse or doctor during a shift change.
Now, with growing evidence that communication breakdowns during such transfers are the single largest source of medical error, the Joint Commission on Accreditation of Health Care Organizations is requiring hospitals for the first time to establish standards for hand-off communications -- and break down long-standing cultural barriers in the exchange of patient information between doctors and nurses.
The stakes are high, as hospitals that fail to comply with Joint Commission patient safety standards risk losing accreditation, which is often required for reimbursement from Medicare and private insurers. Hospitals generally have some hand-off procedures, but they tend to be ad-hoc arrangements that vary from unit to unit or even nurse to nurse. Many hospitals have only begun to implement new checklists, forms and routines that will formalize these structures.
But a few hospitals and health-care quality groups have been ahead of the pack, borrowing communication strategies used in aviation and the military, where hand-off failures can lead to devastating accidents. The non-profit Institute for Healthcare Improvement, for example, is working with hospitals on a communication model known as SBAR -- an acronym for Situation, Background, Assessment and Recommendation -- adapted from a program used to quickly brief nuclear submariners during a change in command.
Oakland, Calif.-based managed-care giant Kaiser Permanente, which operates 30 medical centers, has pioneered use of the model to help nurses and doctors quickly organize their thoughts and convey the most critical information in just 60 seconds. At OSF St. Joseph Medical Center in Bloomington, Ill., cases of harm to patients fell by more than half in the year after the SBAR program was implemented in October 2004. And the Veterans Administration is funding development of a hand-off tool for medical teams using similar principles at its hospitals.
"A hand-off is a precision maneuver, but in medicine it has been left to happenstance," says Richard Frankel, a professor of medicine at Indiana University who is working on safety programs with the VA medical center in Indianapolis.
Reduced work hours for medical residents, which went into effect in 2003, have reduced the likelihood that a patient will be harmed by a resident whose judgment is impaired by fatigue, notes Dr. Frankel, but shorter shifts "just increases the number of hand-offs during any given day not done with precision."
Bungled hand-offs range from a patient getting a dose of a drug that was already administered on a previous shift, to doctors inappropriately reviving a patient because they aren't aware of a "do not resuscitate" order, says Leora Horwitz, a specialist in internal medicine at Yale University and the West Haven, Conn., VA Hospital.
In a survey published last month in the Archives of Internal Medicine, Dr. Horwitz found that few internal-medicine residency programs around the country have a comprehensive transfer-of-care system in place. While the onus shouldn't be on patients to convey such information, she advises patients and families: "If you think there's something important for the doctor to know, say it."
The University Health System Consortium, an alliance of 95 academic medical centers, recently published guidelines on how to best comply with the new Joint Commission standards, including using programs such as SBAR. This fall, the consortium will offer its members on online training program for residents, "Do No Harm," which will include strategies for improving hand-off communication.
John Whittington, patient safety officer at OSF St. Joseph Medical Center, says the SBAR "quick briefing" model can help overcome differing communication styles, such as nurses who give long, descriptive reports and doctors who say, "just give me the headlines," and don't want a nurse's opinion. OSF started training staffers to use the SBAR communication model in 2004, offering pocket cards and laminated "cheat sheets" posted at each phone.
At first, nurses and other staffers were hesitant to provide the "R" -- for recommendation -- to physicians, Dr. Whittington says, but doctors were asked to encourage staff to do so. By last year, the briefing format was used by more than 98% of nurses and the rate of adverse events -- defined as an unexpected medical problem that causes harm -- fell to 39.6 from 89.9 per 1,000 patient days, Dr. Whittington says.
"It does sound like this is something we should have been doing for the last 100 years, but one of the reasons errors are made during hand-offs is the longstanding culture of medicine," says Frank Mazza, vice president of medical affairs at Austin, Texas-based Seton Healthcare Network. Seton began using the SBAR model in its four labor-and-delivery units in January 2005, as part of an effort to eliminate complications for patients and make it easier for nurses to quickly brief each other and doctors.
It was rough at first, Dr. Mazza says, as nurses overcame hesitancy about making assessments, "but we now have complete buy-in from the medical staff."
At Doctors Hospital, in Coral Gables, Fla., part of the Baptist Health South Florida system, patients get a "Ticket to Ride" whenever they leave their hospital room, be it a transfer to another unit or a roundtrip down the hall for an X-ray. With checklists for tests, procedures and nurse's observations, the new peach-colored form helps relay patients seamlessly between staffers -- much the way air-traffic controllers hand off planes as flights move across regional airspaces.
Some large hospital groups and academic medical centers with electronic medical records have had considerable success with automated logs to document transfers, but the use of such technology is still rare. Brigham and Women's Hospital in Boston, for example, has used a computerized sign-out system for several years, and is developing a more-advanced version for the sickest patients in the ICU. David Bates, chief of the Division of General Medicine, says electronic systems are the only way to ensure the safe hand-off of large numbers of patients in a busy hospital, "so a standard set of information can get exchanged every time."
As part of its transition to electronic medical records, Kaiser has developed a Nurse Knowledge Exchange computer program, which allows departing nurses to create customized electronic reports on patients for the incoming nurses, such as lab results or medication changes. But the nurse coming on duty also makes bedside rounds with the outgoing nurse, and engages patients when possible in a discussion of treatments and progress.
"In almost all serious avoidable episodes of patient harm, communication failures play a central role," says Michael Leonard, physician leader for patient safety at Kaiser's Colorado division. By teaching caregivers new models of "structured communication," he adds, "we can make sure that we are all in the same movie."
• Email me at informedpatient@wsj.com1.
Attached an article from a recent Wall Street Journal edition discussing the efforts to reduce the medical error incident rate related to communication errors.
The article describes how several hospitals are developing "structured communication" models to aloow for the seamless transfer of patients from shift to shift.
This is especially important in the context of residency work hour limitations necessitating more frequent patient transfers, which may be associated with a higher error rate unless structured communication models are being followed.
Yours
Bernd Wollschlaeger,MD
PS: you can also find a list of recent e-mails and their content on my blog http://floridadocs.blogspot.com
Hospitals Combat Errors at the 'Hand-Off'- New Procedures Aim to Reduce Miscues as Nurses and Doctors Transfer Patients to Next Shift
June 28, 2006; Page D1
For hospitals, the "hand-off" has long been the Bermuda Triangle of health care: Dangerous errors and oversights can occur in the gap when a patient is moved to another unit or turned over to a new nurse or doctor during a shift change.
Now, with growing evidence that communication breakdowns during such transfers are the single largest source of medical error, the Joint Commission on Accreditation of Health Care Organizations is requiring hospitals for the first time to establish standards for hand-off communications -- and break down long-standing cultural barriers in the exchange of patient information between doctors and nurses.
The stakes are high, as hospitals that fail to comply with Joint Commission patient safety standards risk losing accreditation, which is often required for reimbursement from Medicare and private insurers. Hospitals generally have some hand-off procedures, but they tend to be ad-hoc arrangements that vary from unit to unit or even nurse to nurse. Many hospitals have only begun to implement new checklists, forms and routines that will formalize these structures.
But a few hospitals and health-care quality groups have been ahead of the pack, borrowing communication strategies used in aviation and the military, where hand-off failures can lead to devastating accidents. The non-profit Institute for Healthcare Improvement, for example, is working with hospitals on a communication model known as SBAR -- an acronym for Situation, Background, Assessment and Recommendation -- adapted from a program used to quickly brief nuclear submariners during a change in command.
Oakland, Calif.-based managed-care giant Kaiser Permanente, which operates 30 medical centers, has pioneered use of the model to help nurses and doctors quickly organize their thoughts and convey the most critical information in just 60 seconds. At OSF St. Joseph Medical Center in Bloomington, Ill., cases of harm to patients fell by more than half in the year after the SBAR program was implemented in October 2004. And the Veterans Administration is funding development of a hand-off tool for medical teams using similar principles at its hospitals.
"A hand-off is a precision maneuver, but in medicine it has been left to happenstance," says Richard Frankel, a professor of medicine at Indiana University who is working on safety programs with the VA medical center in Indianapolis.
Reduced work hours for medical residents, which went into effect in 2003, have reduced the likelihood that a patient will be harmed by a resident whose judgment is impaired by fatigue, notes Dr. Frankel, but shorter shifts "just increases the number of hand-offs during any given day not done with precision."
Bungled hand-offs range from a patient getting a dose of a drug that was already administered on a previous shift, to doctors inappropriately reviving a patient because they aren't aware of a "do not resuscitate" order, says Leora Horwitz, a specialist in internal medicine at Yale University and the West Haven, Conn., VA Hospital.
In a survey published last month in the Archives of Internal Medicine, Dr. Horwitz found that few internal-medicine residency programs around the country have a comprehensive transfer-of-care system in place. While the onus shouldn't be on patients to convey such information, she advises patients and families: "If you think there's something important for the doctor to know, say it."
The University Health System Consortium, an alliance of 95 academic medical centers, recently published guidelines on how to best comply with the new Joint Commission standards, including using programs such as SBAR. This fall, the consortium will offer its members on online training program for residents, "Do No Harm," which will include strategies for improving hand-off communication.
John Whittington, patient safety officer at OSF St. Joseph Medical Center, says the SBAR "quick briefing" model can help overcome differing communication styles, such as nurses who give long, descriptive reports and doctors who say, "just give me the headlines," and don't want a nurse's opinion. OSF started training staffers to use the SBAR communication model in 2004, offering pocket cards and laminated "cheat sheets" posted at each phone.
At first, nurses and other staffers were hesitant to provide the "R" -- for recommendation -- to physicians, Dr. Whittington says, but doctors were asked to encourage staff to do so. By last year, the briefing format was used by more than 98% of nurses and the rate of adverse events -- defined as an unexpected medical problem that causes harm -- fell to 39.6 from 89.9 per 1,000 patient days, Dr. Whittington says.
"It does sound like this is something we should have been doing for the last 100 years, but one of the reasons errors are made during hand-offs is the longstanding culture of medicine," says Frank Mazza, vice president of medical affairs at Austin, Texas-based Seton Healthcare Network. Seton began using the SBAR model in its four labor-and-delivery units in January 2005, as part of an effort to eliminate complications for patients and make it easier for nurses to quickly brief each other and doctors.
It was rough at first, Dr. Mazza says, as nurses overcame hesitancy about making assessments, "but we now have complete buy-in from the medical staff."
At Doctors Hospital, in Coral Gables, Fla., part of the Baptist Health South Florida system, patients get a "Ticket to Ride" whenever they leave their hospital room, be it a transfer to another unit or a roundtrip down the hall for an X-ray. With checklists for tests, procedures and nurse's observations, the new peach-colored form helps relay patients seamlessly between staffers -- much the way air-traffic controllers hand off planes as flights move across regional airspaces.
Some large hospital groups and academic medical centers with electronic medical records have had considerable success with automated logs to document transfers, but the use of such technology is still rare. Brigham and Women's Hospital in Boston, for example, has used a computerized sign-out system for several years, and is developing a more-advanced version for the sickest patients in the ICU. David Bates, chief of the Division of General Medicine, says electronic systems are the only way to ensure the safe hand-off of large numbers of patients in a busy hospital, "so a standard set of information can get exchanged every time."
As part of its transition to electronic medical records, Kaiser has developed a Nurse Knowledge Exchange computer program, which allows departing nurses to create customized electronic reports on patients for the incoming nurses, such as lab results or medication changes. But the nurse coming on duty also makes bedside rounds with the outgoing nurse, and engages patients when possible in a discussion of treatments and progress.
"In almost all serious avoidable episodes of patient harm, communication failures play a central role," says Michael Leonard, physician leader for patient safety at Kaiser's Colorado division. By teaching caregivers new models of "structured communication," he adds, "we can make sure that we are all in the same movie."
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