The per-patient cost of hospital care declined 19.4% for aging patients enrolled in a project that provided home-based services. Now an interdisciplinary panel is examining ways to build and pay for a "critical pathway to improved care."
When seriously ill patients seek care at the MedStar Washington Hospital Center, they can expect to get care from the system for the rest of their lives.
Not just health care, but everything required to meet their social and functional needs, says K. Eric De Jonge, MedStar's director of geriatrics.
He calls it "one-stop shopping" and he shared the concept with a panel that met in Cambridge, MA, at the Harvard Law School last week.
De Jonge is involved in an effort by the school's Petrie-Flom Center to address care for people who are seriously ill. The Center is dedicated to the study of health law policy, biotechnology, and bioethics.
It is working with C-TAC, the non-profit Coalition to Transform Advanced Care, to apply an "interdisciplinary analysis to important health law and policy issues raised by the adoption of new person-centered approaches to care for this growing population," according to the center's website.
The panel, which convened last Friday, includes representatives from organizations interested in services for and the needs of the frail, elderly and seriously ill. Panel members were asked to consider a dense draft proposal for "a care model implementation framework" for patients with serious illness.
6 Months to a Framework
The goal is to come up with a framework within six months. The draft document spells out the group's tasks this way:
Define the seriously ill
Identify promising solutions
Examine care outcomes: quality, care experience, and costs
Explore implementation
Evaluate evidence
One key to the panel's success will be to ensure that its recommendations are simple to understand, yet capture variation of needs at a local level, said Khue Nguyen, the COO of C-TAC Innovations.
The guidelines should also allow researchers and providers to drill down and look for the causes of those variations.
"If we are looking to impact a population that, for example, has a very low health status in terms of overall health, a high functional status, and low coping capability, how do we build a service that matches that population?" she asked.
Members of the panel include providers, payers—costs are on the table—and programs involved in the care of the seriously ill. Home health, palliative care, hospice and primary care were all represented in Cambridge.
Timothy Ferris, MD, came across the river from Partners Healthcare, where he is a vice president for population health management and medical director of Massachusetts General Physicians Organization.
Ferris thinks efforts to address the care of the seriously ill will help with problems such as readmissions and the challenges of providing hospital care to an aging population.
Payment Models Are Considered
An issue that came up at the meeting was a desire to avoid duplicating other efforts.
There are many other programs in place or being tested for care of the seriously ill, but Ferris said the Harvard group could play an important role in finding solutions.
"We have not crossed a tipping point with these programs," he said. "We're all still experimenting and we really have to take it to the next level to figure out what is the best way to do this."
While not discussed last week, payment models are also on the panel's agenda. At MedStar, De Jonge said the system assumes all the risk for some of its patients. That allowed the health system to tap into new payment models that include coverage for services such as home-based primary care.
The MedStar program was part of a Centers for Medicare & Medicaid Services demonstration project called Independence at Home. It identified 15 different services that aging patients may need and MedStar put together a team to make them available.
They were able to reduce readmissions and cut costs for high-risk Medicare patients with programs such as house calls and home-based primary care.
Double-Digit Cost Reductions
The C-TAC effort will explore costs and identify payment reforms to allow reimbursement for such teams.
In a study published in the Journal of the American Geriatrics Society, De Jonge reported that cost-per-Medicare-patient enrolled in the program dropped 12.97% to $44,455 from $50,977.
The per-patient cost of hospital care declined 19.4% to $17,805 from $22,096, and costs declined 20.1% for skilled nursing facility care to $4,821 from $6,098, while home healthcare and hospice care costs grew.
There were no differences in mortality or average time-to-death.
De Jonge said he expects the panel to describe the key elements of a care team for the seriously ill and identify payment reforms to allow reimbursement for that team.
So, the panel will need to find solution not just for the delivery of care, but for how to reimburse for care.
"It is a dead end if you just do the right thing, but you don't have a payment model that supports those services," De Jonge said.
The Joint Commission warns that hospital leaders are not promoting changes needed to improve attitudes toward safety, and new research both confirms and challenges the validity of tools designed to measure patient safety culture.
Health system administrators concerned about patient safety can't personally control how expertly care is delivered. But researchers say that engagement from the C-suite is key to the promotion of patient safety culture needed to deliver high quality care.
Now, The Joint Commission (TJC) has issued a Sentinel Event Alert about leadership and safety culture.
Based on analysis of safety data collected by the accrediting organization, the document asserts that "leadership's failure to create an effective safety culture is a contributing factor to many types of adverse events, from wrong site surgery to delays in treatment."
The assessment comes with an 11-item list of safety culture "tenets" for health system leaders follow to promote a positive safety culture. It also comes as new data emerges both supporting and challenging the tools in use to measure safety culture.
Rather than blame and punish those who make or are involved in errors, patient safety culture is moving toward "just culture," where, as described by TJC, "people are encouraged, even rewarded, for providing essential safety-related information."
With the exception of egregious behavior, the idea is to get people to identify and learn from mistakes, not to conceal them. (TJC notes, however, that "clear lines are drawn between human error and at risk or reckless behaviors.")
Stronger safety culture scores correlate with staff reporting events and near misses, according to a January study from the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine.
But there have been reports of "retaliation and intimidation targeting care team members who voice concern about safety and quality deficiencies," according to TJC. It cites instances of "overtly hostile actions, as well as subtle or passive-aggressive behaviors, such as failing to return phone calls or excluding individuals from team activities."
Leadership Involvement Imperative
Recommendations in TJC's "alert" call on leaders to "establish and continuously improve the five components of a safety culture… trust, accountability, identifying unsafe conditions, strengthening systems, and assessment."
The topic of leadership also came up in the National Patient Safety Foundation's status report marking 15 years since the publication of the seminal "To Err is Human" report on medical errors. Number one on that 2015 list of recommendations: "Ensure that leaders establish and sustain a safety culture."
It makes sense that hospitals make sure everyone, from the CEO to the staff who handle waste disposal, be aware of and on board with efforts to protect patients from harm. Several tools enable hospitals and health system to gauge and monitor staff attitudes when it comes to safety.
Other Patient Safety Studies
Recent studies correlating patient safety culture measures with other quality metrics have had both positive and negative results.
One study, published in the BMJ Quality and Safety Journal, looked for a link between patient safety scores and two common hospitals acquired infections: central-line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). It didn't find one.
Jennifer Meddings, MD, is an assistant professor at of the University of Michigan Medical School and lead author of the study. Infection rates improved, she says, but safety scores didn't.
Meddings' findings suggest that the safety culture measure she used, the widely used Hospital Survey on Patient Safety Culture (HSOPS), may not be adequately measuring safety, since surveys like this one take up time that could otherwise be used for patient care, hospitals need to be sure they are valid, she says.
"If you can't correlate this survey with important clinical outcomes, perhaps you should be spending more time on discrete tasks at the bedside," Meddings says.
Jeff Brady, MD, is the director of Center for Quality Improvement and Patient Safety at the Agency for Health Quality Research (AHRQ). Academics and researchers working with his agency developed and vetted the HSOPS survey and are currently working on a revision, which will be tested at 40 hospitals starting next month.
Brady says the HSOPS is a well-vetted tool that has been key to improving safety. Each organization needs to understand its own unique culture, and the survey allows them to do that, he said.
"You figure out what areas you do well in, and you figure out areas where there might be opportunities for improvement and you take the next step by focusing on those areas," Brady said.
He notes that many of the "Tenets of Patients Safety Culture" in the Joint Commission Sentinel Every Alert are also in the HOSPS survey.
In his view, leadership's role is to attend to all of those necessary steps. "Know what your culture is and make sure it's optimalized for safety and quality."
For starters, offer clear, easy-to-digest feedback and "get everyone rowing in the same direction," says the chief clinical officer at Mercy Health. "Good leaders simplify."
Hospital CEO incentives are often driven by how well the system meets financial, and increasingly, clinical goals. At Mercy Health, the occupants of the C-suite are not the only ones who benefit when the Ohio-based system meets or exceeds expectations.
The system's 33,000 employees working within the 23 hospitals in southern Ohio and Kentucky also stand to gain. Once the hospitals' operations meet a simple set of financial and clinical goals, everyone who works at Mercy gets an incentive payment.
Like other systems, Mercy is coping with long list of quality measures required by or requested by government agencies, insurers, and rating sites such as U.S. News & World Report.
The key is to keep things as simple as possible, offer clear, easy-to-digest feedback and "get everyone rowing in the same direction" said Anton Decker, MBBCh, who serves as chief clinical officer of Mercy Health and president of Mercy Health Select.
"It is very hard to keep it all straight, in terms of what is important, what truly changes patient outcomes and, frankly, what has the largest return on investment," Decker said.
He has a three-pronged approach to quality and financial measures linked to staff incentives.
Keep it Simple
The first step is to limit the number of measure that will drive the bonuses. This year, the hospital launched a program that identified six key measures (the work to identify them began last year). It set goals and incentivized the entire staff to meet them. If the six goals are met, the hospital board reviews and approves bonuses. Each region gets a percentage and the board uses a formula that allows the incentive money to "trickle down" to all employees, Decker said.
The measures, many serving double duty for other quality monitoring programs, are:
Net revenue growth
Skilled nursing facility utilization for joint replacement patients in bundled payment programs
Readmission rates
Access to primary care
Implementation of programs to address the opioid epidemic
A package of primary care benchmarks such as blood pressure and colon cancer screenings.
On the 15th of each month, the hospital publishes what it calls the "clinical operation performance report" on the six measures. It first goes out first to 2,500 managers and then to the rest of the staff, both electronically and in booklet format.
In the quest for simplicity, information is provided in data visualizations, rather than numbers-heavy Excel spreadsheets. The visualizations are not fancy; often they are simple line charts. The goal was to create "crystal clear" messages, something Decker and his team worked hard at. They want to ensure that staff could understand at a glance what the graphs are telling them.
"The culture started changing when people started almost looking forward to it—'I wonder how we're doing this month?'" he said. "Previously, this was the purview of select leaders…. Suddenly, 33,000 people had something to rally about."
He called it "the joy of exploration," not a term generally associated with quality measures.
The monthly report features data, plus an executive summary and stories from a clinician and a patient. In addition to the measures in the incentive program, the document and website also include charts on performance in other areas, such as length of stay and patient experience.
The online version is interactive. Clicking on part of a graph opens an in-house intranet page with a monitored discussion group, he said.
The dynamic Decker wants to get away from is "us-versus-them." Staff are incentivized for both clinical and financial performance, and so is the CEO.
Greater Physician Awareness
The system is also using data and staff engagement to drive individual projects, such as trying to break even on Medicare.
Some of the doctors didn't even know the health system lost money on Medicare, Decker said. But, they got on it and reduced Medicare losses on vascular and general surgery.
"We are never going to be successful financially if our clinicians are not a part of operations and finance," he said. "The notion that physicians can just mind their own business and see patients and, miraculously, we'll take care of finances… we just don't think that works. "
Decker said he gets the impression that a lot of hospitals could do more to address their concerns about how to deal with the abundance of quality measures.
"Most health systems just throw their hands up," he said. "They basically do the victim thing––it is being done to them––instead of driving the message and being in control of it.
Not that it's easy.
There are challenges, Decker acknowledges, and the wins are coming slowly. Some problems are stubborn, such as the high use of the emergency department by the hospitals' own employees.
'Good Leaders Simplify'
Health systems that want to try the Mercy Health approach should start by identifying ten items that are important to the organization, and which can be measured. It won't be easy, Decker warned, and it won't be fast.
The alternative? "If everything is important, nothing is important,"
The next step is to hire a data visualization expert to come up with simple, easy-to-understand graphics that will best communicate performance measure to staff.
Finally, keep simplicity in sight. Always.
"Healthcare is complicated everywhere," Decker said. "Good leaders simplify."
Working closely with clinical pharmacists, making evidence-based medication substitutions, and employing smarter dosing can curb costs without reducing quality.
Hospitals have opportunities to reduce the use of expensive or hard-to-get drugs and save money without compromising patient care, according to a hospital pharmacist who spoke at the American Association for the Advancement of Science meeting in Boston Saturday.
The session—which took place at the annual meeting showcasing a range of scientific topics—brought together the issues of drug shortages and high prices. Some of the solutions used at hospitals such as the 465-bed University of Illinois Hospital and Health Science System (UI Health) can address both.
Andrew Donnelly, director of pharmacy services at UI, said that by working closely with clinical pharmacists and setting up a team devoted to address the problems, the system has saved $2.5 million.
"You have to be as smart as you can in terms of using the really expensive medications," he said.
Hospitals need to know that there may be feasible alternatives to medications that suddenly become much more expensive, he said. And if the alternative approaches are evidence-based, the effort won't impact on quality.
If there is no alternative, there should be clear guidelines for approved uses of expensive drugs.
"You don't necessarily have to continue using that very expensive medication in the same manner you do right now,' he said. 'Keep the expensive medication for when there is absolutely no other alternative."
Steep hikes in generic drug prices and expensive new pharmaceuticals have generated much public outrage and are cited as a major factor in rising health costs. And, like shortages, the price hikes come with little warning, Donnelly said.
"I can't tell you how many times a purchaser comes in my office during the week and says 'Andy, we have another shortage' or 'Andy, you won't believe this price increase.' It just happens on a routine basis."
Both trends are likely to continue.
The number of drug shortages has gone down in recent years—from an estimated high of 267 in 2011. But, problems persist, with 120 new shortages reported last year, Donnelly said, citing research from the University of Utah Drug Information Service.
But in terms of costs, an American Hospital Association found that between 2013 and 2015, inpatient drug spending increased an average of 23.4% annually.
By working with a team made up of clinicians and representatives for pharmacy, finance and administrators, UI Health was able to develop strategies to substitute drugs, reduce waste, and develop guidelines, Donnelly said.
He offered the following suggestions:
Determine if there are evidence-based alternatives available to the high-priced drug. If so, remove the high-cost drug from the formulary so it does not continue to be ordered by healthcare providers. Or have well developed guidelines for its approved uses.
Reduce waste associated with the high-expense drugs. This may mean implementing dose rounding where the dose is reduced slightly to avoid having to use another vial for just a small amount of a drug. Some hospitals do this with intravenous immunoglobulin.
Make sure the size of infusion bags does not contribute to waste and consider making multiple syringes out of one vial of the high-expense drug if only small doses are needed.
Try to identify significant drug price increases in as real time as possible to avoid delays in taking action to minimize the financial impact.
Keep as low an inventory of the high-expense drug as possible.
Keep open lines of communication with senior administrations and let them know the impact that they are having on the drug budget.
Use clinical pharmacists to educate prescribers about high drug prices.
All of the above is best handled by an interdisciplinary committee. Clinical pharmacists are key to the effort. Donnelly said he doesn't think most physicians have a good understanding of drug prices.
"Our clinical pharmacists are out in the hospital, they are in the patient units, they are rounding with the medical team," he said. "They are really being proactive with respect to making sure our medication therapy is appropriate."
Data from Missouri shows that 45.8% of death certificates indicated an underlying cause of death "inconsistent with CDC's guidelines for death certificate completion."
Nearly half of the death certificates filed by a group of Missouri hospitals were inaccurate, according to a study from The Centers for Disease Control and Prevention.
Data from hospitals with high inpatient death rates between 2009 and 2012 revealed that 45.8% of death certificates indicated "an underlying cause of death that was inconsistent with CDC's Guidelines for Death Certificate completion."
The study looked at data from eight hospitals with high death rates in two metro areas, Kansas City and St. Louis. The CDC's data on national inpatient hospital death rates was used as a benchmark.
The death certificates were obtained from the Missouri Department of Health and Senior Services Vital Statistics Bureau.
A total of 205 medical charts were randomly selected for review from three disease categories:
Heart disease
Cancer
Renal disease
Only 181 (88%) were reviewed because charts were unavailable or incomplete for 24 patients.
Researchers focused on the three conditions because reported deaths from these conditions were substantially higher in Missouri than in the rest of the United States.
The underlying cause of death was based on a comparison of the chart review with the cause of death recorded on the death certificate. A physician and an epidemiologist examined the certificates for compliance with CDC guidelines.
Researchers found overreporting of heart disease and renal disease and underreporting of cancer as the cause of death.
"Accuracy of death certificates is of paramount importance, considering that such data are widely used to direct public health projects as well as to fund hospital-based programs and clinical research," the report stated.
"However, several studies have demonstrated that death certificates are often completed incorrectly, leading to inaccurate mortality statistics being ascertained from death records."
The CDC researchers note that as a result of the agency's findings, Missouri has adopted a web-based training program on death certificate completion based on the CDC guidelines.
The authors of a paper on the divisive issue of PAS disagree on many points, but are unified on one—doctors should not be required to participate.
As of the November election, five states and Washington D.C. have laws on the books allowing physician-assisted suicide. While it usually takes place outside the hospital setting, the practice is bound to find its way into intensive care units.
Intensivists will need to understand the new laws and be prepared to act in compliance with the law, the wishes of patients and families, their own views, and the policies of the organizations in which they are working.
In Colorado, some hospitals are refusing to allow the procedures in their facilities. According to a statement from SCL Health, the Denver-based Catholic health system: "Any of our patients wishing to request medical aid-in-dying medication will be offered an opportunity to transfer to another facility of the patient's choice."
While state legislatures continue to do their work, the debate among healthcare providers goes on.
The Society of Critical Care Medicine (SCCM) last week published a document spelling out two opposing positions on physician-assisted suicide (PAS) and euthanasia.
The authors disagreed on many points, but were unified on one—doctors should not be required to participate in PAS: "Conscientious objections should be accommodated without unduly obstructing patient's access to medical interventions permitted by law."
The document was published in the group's journal, Critical Care Medicine and was discussed at the annual meeting of the Critical Care Congress.
Two Sides Debate
Wes Ely, MD, of the Vanderbilt University School of Medicine in Nashville, Tennessee helped write the SCCM position paper. Ely opposes the practice, in part because he believes it will lead to the use of euthanasia, where the doctor delivers the fatal dose of medication. With PAS, the doctor prescribes, but does not administer, the fatal dose.
He thinks the two practices are linked.
"Eventually what happens is that somebody comes along and says, 'wait a minute, you've already said that I can get a doctor's help in dying,'" he said. "'But what if have a disease like ALS where I'm totally paralyzed and I can't move? You are discriminating against me now.'"
That patient could insist that if doctor is willing to write a prescription for a patient, he or she should be prepared for patients to ask for an injection, Ely said.
At last's week annual meeting of the SCCM, Ely and co- author Jan Bakker, MD, presented opposing arguments, described in the paper as Position 1 and Position 2. Bakker, is affiliated with University Medical Center, Rotterdam, the Netherlands and Columbia University Medical Center in New York.
In a video of the session, Bakker told the group that PAS has created a new role for doctors: facilitators of dying. He said PAS should be considered an element of end of life care and that he has witnessed both "magnificent dying processes "and "horrible "dying processes.
"You have to have the conviction that there is no other reasonable solution to the suffering of the patient," he said.
Bakker recalled telling a family member that a patient might not die immediately after being removed from life support. The family member asked why he wouldn't give her something to stop her heart after he took the tube out?
"The simple answer in this case is it's illegal. We cannot do that, even in the Netherlands," Bakker said.
The paper brings to light three main questions:
Are there patients for whom death is beneficial?
Is it morally acceptable for physicians to cause death intentionally?
Are PAS and euthanasia morally equivalent to withholding or withdrawing life support (WWLST)?
On the third question, the two sides of the argument go like this:
"WWLST does not always result in death, but death is so likely after withdrawing life support that a physician must accept some degree of moral agency when it occurs."
"We argue that WWLST is categorically different from PAS/E, and we may embrace the former as an integral part of benevolent care while firmly acknowledging the latter as a breach of the patient-physician covenant."
The group's position paper comes as data is emerging about the benefits of providing palliative care services to patients in the ICU. Until recently, the ICU was not seen as an appropriate setting for palliative care, but demand is rising. A single hospital study found that requests from the ICU for palliative care services rose 17.6% between 2004 and 2013.
The paper concludes with this: "As the debate about legalizing PAS/E continues unabated around the world, intensivists will be caught up with these important medical, legal, and ethical issues."
Improvement in care has been seen for privately insured low-income patients and for those at federal health centers. Whether those programs will survive the GOP's plans for the Affordable Care Act is uncertain.
Despite a push to address health care disparities, inequity in delivery and outcomes remains a problem.
Minorities are still more likely than whites to be uninsured and experience bad outcomes. "Blacks and American Indians and Alaska Natives fare worse than Whites on the majority of examined measures of health status and outcomes," according to a 2016 report from the Kaiser Family Foundation.
"Disparities in health and health care remain a persistent challenge in the United States," the report notes.
Now, just as the Trump administration is setting the groundwork to repeal and replace the ACA, two new studies suggest that some Affordable Care Act provisions may be getting at the disparity problem.
Whether those programs will survive the GOP's plans for the ACA is uncertain.
While many of the Obamacare programs are too new to have generated much data yet, one program at Blue Cross Blue Shield of Massachusetts has taken an approach that is similar the ACA accountable care organizations.
Researchers from Harvard Medical School examined the impact of the insurers "Alternative Quality Contract"on spending, as well as process and outcome measures. They compared changes for higher and lower income enrollees from 2006 to 2012. Quality improved for all enrollees, but the improvement in some measures was higher for low income enrollees.
The trend could suggest "a potential narrowing of disparities," according to the team's findings published in the current issue of Health Affairs.
"The hope is that the lessons we can draw from the early Massachusetts experiment… can be useful for other states, other payers, even Medicare, as they embark on payment reform," said Zirui Song, a clinical fellow at Harvard Medical School and lead author of the study.
The authors describe the Blue Cross program as a population-based, global budget model that has "two-sided incentives: It rewards physicians for savings below the risk-adjusted budget (shared savings) but also requires them to share in deficits with Blue Cross Blue Shield of Massachusetts for spending above the budget (shared risk)."
The Blue Cross study looks at privately insured patients, but another study in the same issue of Health Affairs examined outcomes before and after first year of the ACA's Medicaid expansion.
The focus of this study was on the 1,057 federally-funded health centers, with roughly half of those in Medicaid expansion states. The report notes that about 72% of the patients who use these centers have incomes below the poverty level.
Researchers looked at changes in insurance coverage for clinics and found a 11-percentage point decline in uninsured patients and a corresponding 12 percentage point increase in Medicaid coverage. They found that after the expansion in 2014, about 23% of the centers patient population were uninsured in expansion states, compared to 39% in nonexpansion states.
After looking at data from millions of patients, the researchers found improvement in asthma treatment, BMI screening, Pap testing, and blood pressure control. The study was led by Megan Cole, a PhD candidate at the Brown University School of Public Health.
The paper concludes that gains in quality may be even greater for newly expanding states, since baseline uninsurance rates in these states were higher than rates in states that previously expanded. At the same time, the paper reports that, quality may erode at centers in states that elect not to expand.
"As we move forward and think about changes in health reform it will be important to consider how potentially reversing some of these polices the could impact health centers," Cole said.
The impact if the coverage is rolled back. Despite data that some of the ACA provisions could address disparities, the future of those program remains unclear.
Alternative payment models like the one at Blue Cross Blue Shield of Massachusetts may live on in the private sector, but it is uncertain how much changes to the ACA with impact on ACO effort at Center for Medicare and Medicaid Services. In terms of Medicaid, the Republican position is to move responsibilities for the joint state and federal program to the states through block grants.
Hospitals are increasingly looking upstream at how the health of their patients is impacted by access to care and social factors like poverty, unemployment, education and housing. Both studies suggest that ACA program can help boost outcomes for low-income patients who face many of these challenges.
At the same time, the need for such research is highlighted in a report from the National Academies, the venerated Washington DC think tank. That report concludes: "Funding is needed to support research that studies the effects of—and effective strategies to address—the health-related harms of structural racism and implicit and explicit bias across categories of race, ethnicity, gender, disability status, age, sexual orientation, gender identity, and other marginalized statuses."
Insured children who show up in the emergency department are more likely to be admitted to the hospital than those covered by Medicaid and CHIP. But they don't fare any better than those sent home.
Much of healthcare reform is about matching patients to the most appropriate care. Recent studies looking at emergency department admissions offer evidence of how hard that can be.
In New Jersey, an analysis of more than 3 million ED cases found that children with public insurance were less likely to be admitted to hospital, especially during flu season when beds tend to be full.
However, based on data including readmission rates, those who did not stay overnight suffered no bad health outcomes, according to research published in Economics and Human Biology.
The patients who were not admitted via the ED had the same rate of future visits and subsequent admissions as those who were hospitalized. Since the hospitalized patient got no benefit, the authors suggest the finding could be evidence of unnecessary care.
To establish whether unnecessary care is occurring, researchers would have to look at clinical data rather than the claims data used in this study, said Princeton University health economist Janet Currie, a coauthor of the study.
If patients did need additional care, it would show up in the data on subsequent admission and ED visits, Currie said. "If I am really sick and I get sent home, I should end up coming back," she said. "But they're not coming back… What we infer from that is they don't really need to be hospitalized."
While the publicly insured have less access to after-hours and specialist care, once admitted, they receive the same care as privately insured children. However, little research has been done on access to hospital care for publicly insured children, the researchers noted.
The statewide data used in the study covered 2006 through 2012 and looked at claims data for more than 3 million patients. They found the widest difference in admission probability (4.4 versus 4.7) during flu season—or 9,700 more publicly insured children who were not hospitalized.
A Different Twist
A slightly different twist on the impact of insurance in emergency care come from a 2014 study which found that insured patients with severe injuries who were initially evaluated at non-trauma center EDs were less likely to be transferred to trauma centers.
These patients were at risk of receiving suboptimal trauma care because they might not be transferred to Level 1 trauma centers, which are equipped to deal with the most serious cases, the study concluded.
A more recent (2016) study in JAMA Surgery suggests that only one in five patients meeting American College of Surgeon transfer criteria were transferred. "Further study is necessary to critically evaluate whether these ACS criteria identify patients who require transfer," the researchers wrote.
ED Experts Question Findings
Howard Mell, MD, an Illinois emergency medicine physician and a spokesman for the American College of Emergency Physicians, questioned the suggestion that ED clinicians would be less likely to admit publicly insured patients.
ED physicians are blind to a patient's coverage, said Mell. Furthermore, "it is very tough to look at data that is designed for billing and make a good determination as to where this is coming from," Mell said.
The huge volume of data in the Princeton study means the study finding doesn't reflect "the individual thought processes" of physicians, said Karin Rhodes, MD, emergency medicine physician and head of care management design for Northwell Health in New York City.
That there was no benefit to the hospital stay made sense to Rhodes based on her work with the frail elderly.
"The people I work with—geriatricians and palliative care doctors—strongly feel that hospital admissions that are unnecessary increase suffering and cause many adverse consequences." Unnecessary admissions could be harmful for children as well, said Rhodes.
Hospitals could use their in-house clinical data to explore links between insurance status and admissions, Currie said.
"You certainly want to make sure you are admitting the right people," she said.
The new program is designed to help hospitals reduce unwanted variations in cardiac care, lower costs, and improve outcomes.
The Joint Commission has added cardiac centers to the list of services that it certifies. The organization already certifies primary care medical homes, perinatal care, and "disease specific care."
Unlike accreditation, which is granted to an entire hospital or health facility, certification is granted for individual services.
The "Comprehensive Cardiac Center Advanced Certification" will ensure that the programs demonstrate "compliance with consensus-based standards, effective integration of evidence-based clinical practice guidelines, and an organized approach to performance measurement and improvement," according to The JCHO. Reviewers will also look at the communication among care teams, patients and families.
In an announcement of the program, Patrick Phelan of The JCHO Hospital Business Development program wrote that the certification will encourage hospitals to deliver coordinated, and patient-centered cardiac care. The effort should also improve transitions from care settings.
The review will focus "on key processes to assist hospitals with reducing unwanted variations in how cardiac care is delivered to lower costs and improve patient outcomes," he wrote.
The centers will have to offer the services for the following conditions to be considered for certification:
Ischemic heart disease, including valve replacement and repair
Cardiac valve disease
Arrhythmias, including electrophysiology services and outpatient device clinic
Advanced heart failure, including outpatient services
Cardiac arrest, including prevention of in-hospital arrests, resuscitation, and targeted temperature management for cardiac arrest
Cardiac rehabilitation of patients
Cardiovascular risk factor identification and cardiac disease prevention
The development of the certification program involved feedback from a panel of multidisciplinary clinical experts, a national field review, and "pilot surveys to assess the current state of comprehensive cardiac centers and the operational challenges involved in addressing the multiple domains of cardiac patient care and services," according to The JCHO.
Every year about 735,000 Americans have a heart attack, according to the Centers for Disease Control. Heart disease is the leading cause of death for both men and women. About 610,000 Americans die from heart disease each year.
Overuse and underuse are persistent symptoms of a profoundly dysfunctional healthcare system immune to incremental reforms, say the authors of an exhaustive study.
The overuse of health services is old news. In the US, the problem emerges in the form of variations in practice patterns and overdiagnoses. Here, underuse usually falls under the heading of access.
In both cases, efforts are underway to expand coverage and discourage the use of low-value services.
But the worldwide problem of inappropriate care described in a series of research papers released Monday goes beyond anything that could be addressed through quality measures or The Affordable Care Act.
The 27 researchers who contributed to the series published in The Lancet see overuse and underuse as symptoms of a profoundly dysfunctional healthcare system immune to incremental reforms.
They make their case in a series of four articles that describe the problem, identify causes, and call for systemic change. They sum up their findings this way: "Because poor care is ubiquitous and has considerable consequences for the health and well-being of billions of people around the world, remedying this problem is a morally and politically urgent task."
In a related commentary, Donald Berwick, MD, president emeritus and senior fellow at the Institute for Healthcare Improvement, describes the research as a "call-to-arms to improve health care globally by better matching care to needs, and practice to science."
The authors met on Monday in London to discuss the findings. One of them, Lown Institute president Vikas Saini, MD, spoke to HealthLeaders Media last week in his organization's Boston-area office.
The Lown Institute, which inspired and shepherded the research, is working to spark a grassroots movement "to transform the health system," he said.
"One of the things we recognized through the work of the papers, which I don't think we would have recognized without it, is that overuse and underuse occur all around the world," Saini said.
The findings on inappropriate care are staggering.
Some are familiar: The WHO estimates 1.5 million children died of vaccine-preventable illnesses in 2015.
Others findings may be unfamiliar: Hypertension is considered undertreated in the US, where 70% of Americans with hypertension are treated. In sub-Saharan Africa, only 18% receive treatment.
And the lists go on: 500,000 cases of faulty thyroid cancer diagnoses. Excessive antibiotic use in China. Inappropriate hysterectomies and colonoscopies in the US. Unneeded knee replacements in Spain and 6.2 million excess caesarean sections each year—half in Brazil and China.
In France, China, and Cameroon, researchers cite the underuse of anticoagulation drugs in certain patients at high risk of stroke.
Who's to Blame?
Causes of this misdirected care are many, according to the study authors. But they cite three overriding drivers – money, knowledge, and power.
The commercial nature of healthcare is high on the list and the authors are not afraid to use the word "greed" to describe the motivations of for-profit players.
In some cases, underuse is driven by patients, who don't seek or comply with care. Another well-know driver, healthcare financing schemes, often influence provider and hospital behavior.
Yet another driver is the lack of planning, Saini said.
"Hundreds of millions of dollars are devoted to health resources: buildings, hospitals, training of physician and nurses," he said. "Yet, there is remarkably poor clarity on how to figure out what you really need. What does your population need?"
In India, for example, poor care comes from a push to move childbirth into new hospitals instead local birthing centers, which are less expensive and just as safe, Saini said.
In order to address all this, the Lown researchers envision a healthcare system that will be very different than the one we have now. Hospitals will need to find what Saini calls a "glide path" that will allow them to adapt.
"In the end, a highly efficient healthcare system is going to need less hospital care and a lot more outpatient, preventative, primary and in-home care," he said. "People who think deeply and hard about health care see that. Everyone is stuck with the transition. How do we get there?"
Saini believes it will take universal coverage and global payments to hospitals to address the problem. But, he said it will take more research, experimentation, and a political movement to bring about change.
It's About Power
"Care delivery is the net result of the relative power of various stakeholders to influence the process of decision making in the doctor/patient relationship," Saini and his co-authors write.
"Stakeholders with sufficient economic capital can use that ability to financially support and influence others, and reinforce terms most favourable to their interests."
He is convinced that change will not happen without the kind of activism and buy-in he thinks was absent in the run-up to the Affordable Care Act.
"The allocation of healthcare is such an important issue around the world, it really does require a greater engagement on the part of the public in order to come to an understanding of what kind of solutions are going to be appropriate and acceptable to people," he said.
Without it, he said, "We'll see change. We'll see improvements, but not enough to move the needle."
