Every year at this time, you hear warnings that flu season has arrived. New data from the CDC indicates the season is far from over. So, you are urged by health authorities to get a flu shot. What you may not realize is how the flu can affect the hospitals you and your loved ones rely on for care.
In January, the large urban hospital where I am an intern faced the worst flu outbreak it has ever seen. Nearly 100 staff members tested positive for the flu. Residents assigned to back-up coverage were called to work daily to supplement the dwindling ranks of the sick. Every hospital visitor was required to wear a mask upon entry. At one point, every patient in the medical ICU had the flu and the whole unit had to be quarantined. Because of this, the hospital was put on diversion – no new patients could be admitted.
Why was this flu outbreak so bad? Doctors are still trying to understand all the causes, but one likely reason is that hospital staff with symptoms came to work and became a reservoir for the virus. A majority of visitors and patients don’t get their flu shots, making matters even worse.
Once administrators caught on to the mess this year’s flu was creating, they took some new and aggressive measures. In addition to the free vaccines provided to employees every year, they performed daily symptom check-ins, encouraged sick days, and held an influenza town hall. After discussion with the State Department of Health, medical residents were provided free Tamiflu and urged to take it as prophylaxis. Only 40% picked it up. Residency directors asked symptomatic house staff to stay home. A positive flu swab meant a mandated five days off work. One month later, we are still required to check in daily and confirm that we are symptom-free via a text messaging system or a checklist circulated to each hospital floor. These responses were effective, and the wave of flu appears to have passed. We must now plan ahead to prevent the next outbreak.
Say you want to know which baseball players provide the most value for the big dollars they’re being paid. A Google search quickly yields analytics. But suppose your primary care physician just diagnosed you with cancer. What will a search for a “high value” cancer doctor tell you?
Public concern over bloated and unintelligible medical bills has prompted pushback ranging from an exposé by a satirical TV show to a government edict that hospitals list their prices online. But despite widespread agreement about the importance of high-value care, information about the clinical outcomes of individual physicians, which can put cost into perspective, is scarce. Even when information about quality of care is available, it’s often unreliable, outdated, or limited in scope.
For those who are sick and scared, posting health care price tags isn’t good enough. The glaring information gap about the quality of care must be eliminated.
“When people are comparison shopping, knowing the price of something is not enough,” notes Eric Schneider, a primary care physician and senior vice president of policy and research at the Commonwealth Fund. “People want to know the quality of the goods and services they’re buying.”
Awareness about PD and its treatment and implications thereof are critical in ensuring reduced risks for this patient population. People with PD are very dependent on their medication, and timing of this medication is critical to maintaining good symptomatic control. In the outpatient setting, the main goal of medication management for these patients is to provide as much ON time as possible while minimizing side effects of the medications, such as dyskinesia. ON time describes a period of time when the medications are working and symptoms are controlled. Patients with advanced PD may have considerable difficulty with motor fluctuations if they transition from the ON state to an OFF state when the medication effect has worn off and they are symptomatic. The fine tuning of the medication regimen is pain-staking and often the result of multiple office visits and telephone calls to arrive at the best schedule customized for the patient. This can often result in seemingly unconventional timings (sometimes on the quarter after the hour) and at time q3 or even q2 intervals. Deviations from these regimens, even as little as 15 minutes delays, can have deleterious effects on patients with PD, as detailed above.
When patients with PD enter the hospital, attention is seldom paid to the exact timing of medication administration. If a patient takes a particular medication six times daily, ordering the medication six times daily in the hospital defaults to standard timings that often are different from the patients’ own regimen, causing timing errors. Almost 75% of PD patients who enter the hospital have delays in their medications and more than 60% of these patients can have complications during their hospitalization because of these delays.
The message comes in over the office slack line at 1:05 pm. There are four patients in rooms, one new, 3 patients in the waiting room. Really, not an ideal time to deal with this particular message.
“Kathy the home care nurse for Mrs. C called and said her weight yesterday was 185, today it is 194, she has +4 pitting edema, heart rate 120, BP 140/70 standing, 120/64 sitting”
I know Mrs. C well. She has severe COPD from smoking for 45 of the last 55 years. Every breath looks like an effort because it is. The worst part of it all is that Mrs. C just returned home from the hospital just days ago.
Historically, the Centers for Medicare & Medicaid Services’ (CMS) stance on the influence that social determinants of health (SDOH) have on health outcomes has been equal parts signal and noise. In April 2016, the agency announced it would begin adjusting the Medicare Advantage star ratings for dual-eligibility and other social factors. This was amid calls for increased equity in the performance determinations from the managed care industry. At the same time, CMS continued to refuse risk-adjustment for SDOH in the Hospital Readmissions Reduction Program (HRRP) despite the research supporting the influence of these factors on the HRRP.
It wasn’t until Congress interceded with the 21st Century Cures Act that CMS conceded to adjusting for dual-eligibility under the new stratified approach to determining HRRP penalties beginning in fiscal year 2019. The new methodology compares hospital readmission performance to peers within the same quintile of dual-eligible payer mix. The debate surrounding the adjustment of incentive-based performance metrics for SDOH likely is to continue, as many feel stratification is a step in the right direction, albeit a small one. And importantly, the Cures Act includes the option of direct risk-adjustment for SDOH, as deemed necessary by the Secretary of Health and Humans Services.
SDOH are defined as “the conditions in which people are born, grow, live, work and age.” The multidimensional nature of SDOH reach far beyond poverty, requiring a systemic approach to effectively moderate their effects on health outcomes. The criteria used to identify SDOH include factors that have a defined association with health, exist before the delivery of care, are not determined by the quality of care received and are not readily modifiable by health care providers.
The question of modifiability is central to the debate. In the absence of reimbursement for treating SDOH, providers lack the resources to modify health outcomes attributable to social complexities. Therefore, statistical adjustments are needed to account for differences in these complexities to ensure risk-adjusted performance comparisons of hospitals are accurate.
Today’s health care providers face the formidable challenge of delivering better, more affordable and more convenient care in the face of spiraling care costs and an epidemic of chronic disease. But the most innovative among them are making encouraging progress by “integrating”—which in this context means working across traditional boundaries between patients and clinicians, health care specialties, care sites and sectors.
The impulse to do so is shrewd, according to our innovation research in sectors from computer manufacturing to education. We’ve found that when a product isn’t yet good enough to address the needs of a particular customer segment, a company must control the entire product design and production process in order to improve it. This is necessary because in a “not-good-enough” product, unpredictable and complex interdependencies exist between components, so each component’s design depends on that of all the others.
Given this, managers responsible for the individual components must collaborate—or integrate—in order to align components’ design and assembly toward optimal performance. IBM employed an integrated strategy to improve performance of its early mainframe computers, and this enabled the firm to dominate the early computer industry when mainframes weren’t yet meeting customers’ needs.
In health care delivery, such integration is analogous to, but something more than, coordinated care. It means assembling and aligning resources and processes to deliver the right care, in the right place, at the right time. This type of integration is a core aspiration of innovative providers leading hot-spotting and aging-in-place programs, capitated primary care practices, initiatives addressing health-related social needs, and other care models that depart from America’s traditional, episodic, acute-care model. How are they tackling it? They’re leveraging very specific tools to facilitate work across boundaries. Here are six of the most common we uncovered in our research:
The United States ranks number one in the world for health care spending as a percentage of GDP. That sounds great… but, for instance, Texas ranks only 11th worldwide when it comes to performance. That’s because of access to care.
The country’s health care rankings are likely to get worse as 673 rural hospitals in the U.S. are at risk of closing. Here’s what has happened: the need for care greatly outpaces available funding, especially for public hospitals. Something must be done.
If public funding is no longer available, alternative funding can be secured in numerous ways. The simplest way to access alternative funding is through a public-private partnership (P3) engagement. However, alternative funding for public hospitals, health care clinics and university medical centers can be found from other sources as well. Finding funding is not a problem when private-sector investors, large equity funds, pension programs, asset recycling and EB5 programs all stand ready to invest in public-sector projects.
Moving to a P3 health care model would allow hospitals to secure immediate funding and utilize private-sector expertise and best practices while transferring all risks. The launch of health care P3s would also ensure new construction, new jobs and hundreds of additional health care options for people. Continue reading…
Seema Verma, the Trump appointee who runs Medicare, has had an active week. The problem facing much-beloved Medicare is one that faces every other government-funded healthcare extravaganza: it’s always projected to be running out of money. Medicare makes up 15% of the total federal budget. That’s almost $600 billion dollars out of a total federal outlay of $4 Trillion dollars. The only problem here is that revenues are around $3.6 trillion. We are spending money we don’t have, and thus there there is constant pressure to reduce federal outlays.
This is a feat that appears to be legislatively impossible. The country barely is able to defund bridges to nowhere let alone try to reduce health care spending because, as everyone knows, any reduction in health care spending will spawn a death toll that would shame the black plague. The prior administration’s health policy wonk certified approach was to change the equation in health care from paying for volume to paying for value. This, we were assured, would allow us to get better healthcare for cheaper! And so we got MACRA, The Medicare Access and CHIP Reauthorization Act, that introduced penalties for doctors unable to provide ‘good’ care. Never mind that in some years good care means you treat everyone with a statin, and in others it means treat no one with a statin. When in Rome, live like the Romans. In 2018 parlance, that roughly translates to “check every box you can and everything will be all right.”Continue reading…
In an effort to help women make informed decisions about where to deliver their babies, we set out to collect a comprehensive, nationwide database of hospitals’ C-section rates. Knowing that the federal government mandates surveillance and reporting of vital statistics through the National Vital Statistics System, we contacted all 50 states’ (+Washington D.C.) Departments of Public Health (DPH) asking for access to de-identified birth data from all of their hospitals. What we learned might not surprise you — the lack of transparency in the United States healthcare system extends to quality information, and specifically C-section data. Continue reading…
Last week, Facebook’s unprecedented stock price collapse triggered by concerns over personal data privacy, as well as same-day commentary regarding GlaxoSmithKline’s investment in 23andMe to gain access to its customers’ genomic data, reignited a national dialogue vis-à-vis our rights to our data, especially our health data. Three years ago, our nation’s first National Coordinator for Health IT foresaw an impending “gold rush” for valuable personal health data. Myriad headlines such as Bloomberg’s “IBM Buying Truven for $2.6 Billion to Amass More Health Data” proved him right and fueled this national dialogue.
However, there has been far less discussion about the flip-side of this coin: accessibility of knowledge gleaned from people’s data, by the people whose experiences contributed to its development and the people who need it to save lives. Policymakers have noted that, “We must develop a communications system so that the miraculous triumphs of modern science can be taken from the laboratory and transmitted to all in need.” Unfortunately, that statement, attributed to Senator Lister Hill and inscribed on a wall inside the U.S. National Library of Medicine (the world’s largest biomedical library), was made in 1965! That predates by a year Dr. Martin Luther King Jr.’s observation that, “Of all the forms of inequality, injustice in health is the most shocking and inhuman.” Indeed, inequitable access to knowledge, resulting from society’s failure to realize Senator Hill’s vision over half a century later, exacerbates such injustices while costing lives.