By JANE SARASOHN-KAHN

Revenues = volume x price. This is the financial reality for every organization that makes its money serving customers, whether for-profit or not-for-profit.

For the U.S. hospital sector, both volumes and prices are falling, leading to a depressed top-line. Reimbursement reductions from Medicare, Medicaid and commercial health plans are all under pressure: that’s the ‘price’ part of the equation. On the volume multiplier, the recession economy has caused patients to delay care, such as elective surgeries. Hospitals are forced to scrutinize every aspect of operations, according to Hospital Revenues in Critical Condition; Downgrades May Follow, from Moody’s Investors Service.

Moody’s points to declines in inpatient admissions, and falling outpatient indicators including ER visits, outpatient visits, and outpatient surgeries, all due to the “sluggish economy,” the agency wrote.

Exacerbating the negative bottom-line impact is the continued growth of uncompensated care: that is, health services provided to patients who leave the hospital without paying their bill.

Continue reading “U.S. Hospitals Face Gloomiest Economic Outlook in 20 Years”

By ELAINE SCHATTNER, MD

Some­thing I learned as a medical intern is that there are worse things than dying.

As I recall, it was sometime in April, 1988. I was putting a line in an old man with end-​​stage kidney disease, cancer (maybe), heart failure, bac­teria in his blood and no con­sciousness. Prince was on the radio, loud, by his bedside. If you could call it that – the uncom­fortable, cur­tained com­partment didn’t seem like a good place for resting.

An attending physician, a smart guy I respected, approached me as I com­pleted the procedure.

“It’s kind of like Dante’s seventh circle,” he noted.

Indeed. A clear, flexible tube drained greenish fluid from the man’s stomach through his nose. Gauze covered his eyes, just par­tially. His head, hands and feet swelled with fluid. A semi-​​opaque hard-​​plastic instrument linked the man’s trachea, through his paper-​​taped mouth, to a noisy breathing machine. His skin, barely covered by a stained hos­pital gown, was pale but blotchy from bleeding beneath. An arterial catheter inserted by his wrist, just where I might have taken his pulse had he been healthier. A fresh adhesive covered the cotton gauze and brownish anti-​​bacterial solution I’d placed over his lower right neck.

“Yeah,” I said as we walked out of the room to review another patient’s chart.

Continue reading “How to Avoid Death in the ICU”

By HAROLD POLLACK

From the Chicago Tribune and AP.

The decisions were announced to the hospitals Tuesday morning, Revenue Department officials told The Associated Press. They follow last year’s Illinois Supreme Court ruling that found a central Illinois hospital wasn’t doing enough free or discounted treatment of the poor to qualify for an exemption, costing it $1.2 million in local property tax payments per year.

In addition to Prentice Women’s Hospital [a Northwestern facility] in Chicago’s Gold Coast neighborhood, the revenue department now has decided that Edward Hospital in Naperville and Decatur Memorial Hospital in Decatur don’t quality for property tax exemptions. The hospitals have 60 days to ask an administrative law judge to review the decisions. In Illinois, property taxes are collected by county governments, and the Department of Revenue decides which institutions are eligible for tax exemptions.

In a written statement, Illinois Hospital Association President Maryjane A. Wurth said she was disappointed and “deeply concerned” by the Revenue Department’s preliminary rulings, and worries that the hospitals will be forced to reduce services and increase costs for patients and employers.

By DAVID E. WILLIAMS

After reading the July edition of Health Affairs, I’m concerned about the impact of Accountable Care Organizations (ACOs) on cost trends in the US health care system.

In The Accountable Care Organization: Whatever Its Growing Pains, The Concept Is Too Vitally Important To Fail, Francis Crosson of the Kaiser Permanente Institute for Health Policy plays down the various criticisms of ACOs (that they may stifle innovation, unleash a torrent of regulation, and rely too heavily on fee for service payment methodologies) and argues that we need to help them succeed because there are no good alternatives. If not,

both public and private payers will probably be forced into across-the-board reductions in payment rates to providers, because the state of the economy will require cost reductions, and there will be no other obvious course to pursue. Reductions in quality and access may follow…

But the emergence of ACOs is driving hospitals to consolidate, buying other hospitals and physicians practices.

Continue reading “Let’s Hope ACOs Aren’t Our Last, Best Chance for Delivery System Reform”

By PAUL LEVY

It has been almost four years since I commented on the annual hospital ranking prepared by US News and World Report.  I have to confess now that I was relatively gentle on the magazine back then.  After all, when you run a hospital, there is little be gained by critiquing someone who publishes a ranking that is read by millions.  But now it is time to take off the gloves.

All I can say is, are you guys serious?  Let’s look at the methodology used for the 2011-12 rankings:

In 12 of the 16 [specialty] areas, whether and how high a hospital is ranked depended largely on hard data, much of which comes from the federal government. Many categories of data went into the rankings. Some are self-evident, such as death rates. Others, such as the number of patients and the balance of nurses and patients, are less obvious. A survey of physicians, who are asked to name hospitals they consider tops in their specialty, produces a reputation score that is also factored in.

Here are the details:

Survival score (32.5 percent). A hospital’s success at keeping patients alive was judged by comparing the number of Medicare inpatients with certain conditions who died within 30 days of admission in 2007, 2008, and 2009 with the number expected to die given the severity of illness. Hospitals were scored from 1 to 10, with 10 indicating the highest survival rate relative to other hospitals and 1 the lowest rate. Medicare Severity Grouper, a software program from 3M Health Information Systems used by many researchers in the field, made adjustments to take each patient’s condition into account.

Continue reading “US Rumor and Hospital Report”

By PAUL LEVY

The UPMC kidney transplant story continues to develop.  This was the one where a doctor and nurse were disciplined in a matter that clearly reflected some systemic problems, more than personnel problems regarding those two people.

Now UPI reports:

A report by a federal agency on a kidney transplant at the University of Pittsburgh Medical Center suggests more problems than the hospital has acknowledged.

The Centers for Medicare and Medicaid Services said its investigation found the nephrologist should have been aware the kidney donor was infected with hepatitis C, the Pittsburgh Post-Gazette reported Tuesday. The hospital has suspended the lead surgeon and the transplant coordinator.

The CMS report said the test results were available for two months in the donor’s medical record. But none of the doctors and nurses apparently reviewed the record, and the kidney was transplanted into a man who was not infected with the virus.

Continue reading “When Will UPMC Explain the Whole Story?”

By MICHAEL MILLENSON

The way that Michael Long and Sandeep Green Vaswami want to change hospital care may well rank as both the most commonsensical and most hopeless health reform proposal ever. The real question is whether they can show the same tenacity in pursuing their goal as an elderly Jewish woman from Munster, Ind., who has invested nearly two decades in a similar effort.

What the two men are advocating is simple: hospitals should offer the same level of professional staffing and patient care on weekends as during the rest of the week. They should do this, the two men write in the Health Affairs blog, because trying to cram seven days of care into five leads to a cascade of problems that harm and even kill patients. It also costs a lot of money.

That’s the commonsense part. The hopeless part is that Long and Vaswami, both affiliated with the Institute for Healthcare Optimization, seem to believe that doctors, nurses and hospital execs will read their article and then spontaneously volunteer to work the weekend shift.

American hospitals are complex entities, but at heart they remain the doctor’s workshop, dependent upon the goodwill of physicians who admit and care for patients. Maintaining that goodwill requires treading carefully. For instance, telling a neurosurgeon, “You’re working Wednesday through Sunday this week” would rank high on the list of what a friend of mine calls a “career-limiting event.”

Long and Vaswami are aware they’re tampering with long-standing tradition, but as justification they offer a disturbing catalog of the effect of care controlled by the calendar.

To begin with, bunching scheduled admissions in midweek often overwhelms the staff, leading to “significant” increased risk of patient death or admission to the Intensive Care Unit. Filled beds force emergency rooms to discharge patients to “inappropriate care locations,” with the hospital relying on specialized teams to ride to the rescue “when patients deteriorate because of inadequate care.” At the same time, “medically appropriate transfers … may also be delayed or rejected.”

And that’s when hospitals are operating normally. Patients admitted over the weekend face an increased risk “because critical diagnostic or therapeutic modalities are not available,” while patients staying over the weekend experience “delays at best and deterioration in clinical condition at worst.”

Continue reading “The Most Commonsensical And Hopeless Reform Idea Ever”

By KENT BOTTLES, MD

The decision by the Obama administration to employ “mystery shoppers” to pose as patients to see how difficult it is to get an appointment with a physician has sparked criticism from physicians. However, access to primary care physicians is a very real public policy issue that needs to be understood if we are to successfully care for the more than 30 million Americans who receive coverage under the Affordable Care Act.Is the use of “mystery shoppers” a bad idea?

Dr. Raymond Scalettar certainly thinks it is a bad idea. “I don’t like the idea of the government snooping. It’s a pernicious practice – Big Brother tactics, which should be opposed.”

Dr. George Petruncio says, “This is not the way to build trust in government. Why should I trust someone who does not correctly identify himself.”

Westby Fisher, MD writes in his blog: “When information gathering trumps patient care - particularly fictitious care - we’ve got a problem. Is this a new quality standard we can expect from our new government health care initiative?  Just like scam-artists that phish for unsuspecting people’s financial information online, governmental appointment phishing should not be tolerated in any way, shape, or form. It is fraud – plain and simple.”

Several physicians on twitter retweeted Dr. Fisher’s blog post and indicated they agreed with his analysis.

Continue reading “Are Mystery Shoppers Such a Bad Idea for Health Care Quality Improvement?”

By BOB WACHTER, MD

Last week marked the 30th anniversary of the first reports of a cluster of cases of pneumocystis pneumonia in gay men in Los Angeles. While I’ve recently heard a number of reflections on these early years, I’ll focus on a topic that I haven’t seen covered: how AIDS transformed training – including my own – and what the emergence of AIDS taught me about innovation and, yes, opportunism.

In early 1982, I was a 3rd year student at Penn on my first medicine ward rotation. One night, my team admitted a young gay man with a bizarre story: progressive wasting, spiking fevers, profound dyspnea, and diffuse infiltrates on his chest x-ray. The next morning, I presented the case to my attending, David Goldmann. Having just read reports of a similar illness galloping through urban gay communities, at the end of my presentation David said gravely, “This thing” – the disease didn’t yet have a name – “is changing the way we practice medicine.”

When I arrived at UCSF in 1983 to begin my internal medicine residency, it didn’t cross my mind that this decision would guarantee that my training would be dominated by this new scourge. In 1985, as a third year resident, I jotted down some of my reflections in an essay. It began:

Like many of today’s interns and residents training in San Francisco, New York, and Los Angeles, I have cared for many more patients with Pneumocystis carinii pneumonia than pneumococcal pneumonia, more patients with Kaposi’s sarcoma than breast cancer, and more patients with cryptocococcal meninigitis than meningococcal meningitis… This realization has prompted me to consider the impact of AIDS on medical residency training.

I sent this paper, entitled “The Impact of AIDS on Medical Residency Training,” off to the New England Journal of Medicine. Of course, this was a naïve and hubristic thing for a resident to do, but I really didn’t know any better. A few weeks later, while on the wards at the VA, I received a page for an outside call. “Hi, this is Dr. Marcia Angell,” said the voice on the other end. “I’m an editor at the New England Journal. We really liked your article but we’ll need a few changes before we publish it.”

Continue reading “A Look Back – 30 Years Later – At The Impact Of AIDS On Residency Training”

By JOE FLOWER

There is a way to avoid a collapse of healthcare in this country.

It’s getting scary.

We are facing, before the end of this decade, a bifurcated future. The way things are going now—with the economy wheezing, doctors bailing, chronic disease rising fast, boomers sliding out of the Viagra years into the Depends years, reimbursements getting squeezed ever tighter, Medicaid sputtering on fumes, and 30 million or more new people soon swarming our doors with insurance cards—if we don’t pull a rabbit out of a hat real soon now, we’re in serious trouble.

If we just muddle along, the best we can hope that “trouble” will look like is horrifying gridlock, no options, no exit. That would be the good outcome. The bad outcome would be the destruction by strangulation of all these great institutions, the utter collapse of our ability to serve this society with real medicine, real healing, real help.

The good news? There is a hat, and it has a rabbit in it.

Continue reading “Five Things Hospitals and Health Systems Have to Get Good at Fast”