Thursday, 24 December 2015
Wednesday, 23 December 2015
Tuesday, 22 December 2015
State Highlights: In Florida, Providers’ Medicaid Payment Complaints Decrease; South Carolina VA Hospital Hires Surgeon Accused of Incompetence
Monday, 21 December 2015
Friday, 18 December 2015
Thursday’s announcement by Kaiser Permanente that it plans to open its own medical school in Southern California has attracted a lot of attention in the health care community.
But Kaiser is actually at the trailing edge of a medical school expansion that has been unmatched since the 1960s and 1970s, say medical education experts. (Kaiser Health News is not affiliated with Kaiser Permanente.) In the past decade alone, according to the Association of American Medical Colleges, 20 new medical schools have opened or been approved.
That’s no coincidence. In 2006, the AAMC called for a 30 percent increase in medical school graduates by 2015 to meet a growing demand, both through expanded class sizes and newly created medical schools.
“We’re on track to meet that 30 percent increase in the next three or four years,” said Atul Grover, AAMC’s chief public policy officer. “Enrollment is already up 25 percent since 2002.”
Many of the new schools focus on producing more primary care doctors — those specializing in pediatrics, family medicine or general internal medicine. In fact, Kaiser Permanente already has a partnership with the University of California, Davis in the northern part of the state on a fast-track training program for primary care.
But Kaiser leaders say their new school (projected to enroll its first class in 2019) is about more than just primary care.
“We need to prepare physicians for the way health care is delivered in the future,” said Dr. Edward Ellison, executive medical director for the Southern California Permanente Medical Group. He said students need to learn not just medicine, but about integrated systems of care and how to work in a much different medical environment. “Our advantage is we can start from scratch,” he said.
Another advantage is the HMO’s deep pockets.
“They’ve got huge resources,” said George Thibault, president of the Josiah Macy Jr. Foundation, which focuses on medical education. “This is a grand experiment, but if anybody can do it, Kaiser can.”
Kaiser Permanente is far from the first health care provider to launch its own medical school — the Mayo Clinic has had one since 1972 and is about to expand that school from its home base in Minnesota to its satellite campuses in Arizona and Florida.
Thibault said health-provider systems are already heavily involved in the new medical schools, often as partners with degree-granting universities, “which itself is a new trend.” For example, on Long Island, the North Shore-LIJ Health System co-launched a medical school with Hofstra University in 2011.
One big question is whether all these new schools will eventually produce more students than there are residency positions, which are necessary to complete the training. The federal government, which funds the majority of those residencies through the Medicare program, capped the number of residencies it would fund in the 1997 Balanced Budget Act.
Currently there are about 27,000 residency slots available each year, which are filled by students who have earned M.D. or D.O. degrees (doctors of osteopathy) in the U.S., as well as foreign medical school graduates and U.S. citizens who have graduated from medical schools overseas.
Between the new M.D.-granting schools and a rapid expansion of osteopathic medical schools, AAMC’s Grover said, demand will soon outstrip supply. Residency slots “are growing at about 1 percent per year,” he said (mostly funded by health systems themselves since Medicare will not), “while undergraduate medical education is growing about 3 percent per year.”
But Edward Salsberg of George Washington University, who has spent a career documenting health workforce trends, said any potential conflict is still a long way off.
“When you start with an excess of 7,000 slots” of residencies over graduating U.S. medical students, “it takes a very long time” to consume that excess, he said. By the year 2024, he and others concluded in a recent article in the New England Journal of Medicine, there will still be 4,500 more slots than graduates.
“So yes, U.S. medical students will have a slightly more limited range of specialties to choose from,” said Salsberg, “but still plenty of room.”
There are also questions about whether there even is a doctor shortage that all these new schools are aiming to alleviate.
Grover, whose organization has led the call for more doctors, said the anticipated shortage of primary care physicians might not be as acute as originally thought. That’s because the U.S. is producing dramatically more nurse practitioners and physician assistants, who also provide primary care.
That’s probably a good thing, at least in supply terms, said Thibault of the Macy Foundation. Because it turns out that many students graduating from new primary care-focused school’s programs are in fact opting to become specialists instead.
“The career choices in the new schools look remarkably similar to career choices of more traditional schools,” he said. The graduating medical students “are responding to the same set of signals and stimuli” about prestige, income and lifestyle.
Thursday, 17 December 2015
Kaiser Permanente, the managed health care giant that now offers patients an integrated system combining insurance, hospitals and outpatient physicians, is adding a Southern California medical school to its portfolio, the company announced Thursday.
The nonprofit HMO, based in Oakland, Calif., will open the Kaiser Permanente School of Medicine in 2019. No specific site has been selected.
“This is a natural evolution for us,” Kaiser’s CEO Bernard Tyson said in an interview. “We are very motivated in being part of the transformation of the entire health care ecosystem.”
Kaiser says it will base physician training on “strategic pillars,” including providing care beyond traditional medical settings, emphasizing collaboration and teamwork and addressing health disparities.
Kaiser, which serves 10.2 million members, is known for providing coordinated care in a technology-driven environment. It was an early adopter of electronic health records and uses its system to reach patients with basic and complex medical needs.
Kaiser says it is committed to attracting a diverse pool of students “to better reflect the communities we serve,” said Dr. Edward Ellison, executive director of the Southern California Permanente Medical Group.
In a major analysis last year, Kaiser was cited as closing the race gap in managing heart disease and diabetes, diseases which account for much of the reason African Americans have shorter life expectancies than Caucasians.
The HMO has long been involved in medical education — but at the residency level. It trains more than 600 residents every year.
Kaiser’s move is unusual. The nation’s 145 medical schools are mostly affiliated with universities, although the Mayo Medical School campus operates within the Mayo Clinic in Rochester, Minnesota.
“There are precedents, but this will be different,” John Prescott, chief academic officer with the American Association of Medical Colleges, said of Kaiser’s new school. “It’s an integrated health care system that’s looking at developing a medical school. I think there will be some surprises as the school unfolds.”
Prescott said the school will need to be accredited and that process could take several years. Twenty new medical schools have opened in the U.S. since 2002, he said, and many of them feature “innovative models,” he said.
Still, building a new medical school is “fraught with risk,” said John Deane, president of Advisory Board Consulting and Management. He said it could be a “huge waste of money” if Kaiser were to replicate the existing model of specialty-focused academic medical centers.
“On the other hand,” he said, “they have an opportunity to do this in a new and different way that could be a form of disruptive innovation that could become a new standard for teaching doctors.”
Tyson and Ellison both seemed focused on innovation.
“I’m as interested and motivated and part of the sponsorship of this 21st century new medical school if I were a physician myself,” Tyson said.
State Highlights: Iowa’s Projected Savings For Medicaid Switch Lowered To $47M; Va. Governor To Present Budget Plan
Wednesday, 16 December 2015
Tuesday, 15 December 2015
State Highlights: Michigan To Vote On Health Insurance Tax; Costs Continue To Be Barrier In Coverage, Study Finds
State Highlights: Battle Lines Drawn As Conn. Governor Eyes Hospitals To Close Budget Hole; Laws To Relieve Doctor Shortages Stall
Saturday, 12 December 2015
This week Connecticut’s leaders had to close a $350 million hole in the state’s budget. One place they cut is hospital funding, and that’s making hospital executives furious.
The battles lines are clear. Gov. Dannel Malloy, a Democrat, says the hospitals are getting rich off taxpayers, making more money than in past years — thanks, in part, to the Affordable Care Act. So he thinks hospitals can afford to give some money back.
“If you make almost a billion dollars a year, how bad are things?” Malloy asks. “If you’re having the best results in recent history in hospital performance, why do you need the citizens of Connecticut to give you an additional $500 million?”
Malloy is making his argument personal — taking aim at the high salaries of hospital CEOs. Many of the executives of the state’s nonprofit medical institutions make at least a million dollars a year, he points out.
“If they’re hurting so bad,” Malloy says, “why are they paying their chief executives $3.5 million dollars?”
But where the governor sees bloat, the hospitals see a politician using them as easy targets. The medical institutions are paying for political-style advertising to tell constituents that his cuts will have a serious, negative effect on patient care.
“Longer wait times, fewer cancer screenings, and nurses will be let go,” one ad says. “Tell Gov. Malloy to stop cutting our hospital care. Lives depend on it.”
The hospitals say bringing up CEO pay is an irrelevant distraction. Cut it in half and you’d barely make a dent in the state’s budget problem, they say.
Dr. John Murphy, who runs Western Connecticut Health Network, says there’s a bigger problem — the governor is either misrepresenting hospital economics, or he doesn’t understand them.
“If you look at, how much money did you really make — operating income? If that’s the number,” Murphy says, “and it’s a pure accounting number, we lost tens of millions of dollars last year.” As for 2015, he says, “I’m sure it’s worse.”
The governor’s staff sees the hospital’s balance sheet differently. If lower-paid hospital employees and small programs are taking a hit because of the state cuts, Malloy’s office argues the blame should be on hospital boardrooms — not the state government. It’s the board members who are prioritizing executive salaries over other financial needs.
This public fight between the state and its medical institutions is playing out largely because of what the hospitals say is a broken promise.
In 2012, the state of Connecticut implemented a new hospital tax. The hospitals would pay around $350 million a year to the state, and all of that money — if not more — was supposed to be returned to them as Medicaid payments.
But that was then. Until Tuesday, the state budget was out of balance. To help fix it, Malloy wanted to cut another $63 million to hospitals; lawmakers put about half of that back. But the numbers still seem out of whack to Patrick Charmel, the CEO at Griffin Hospital, an independent nonprofit in Derby, Conn.
“So, now we’re talking over half a billion dollars,” Charmel says. “That’s what hospitals are paying in terms of the tax. And, essentially, we’re not getting any of that back.”
He thinks hospitals have cut all they can, despite what Malloy thinks.
“When there’s a cut in state payments to hospitals or federal payments to hospitals, it’s got to come out of care delivery,” Charmel says. “There’s nobody else to shift it to.”
Medicaid is lurking in the background of the discussion. The state says more people than ever are getting Medicaid, and Medicaid payments to hospitals have more than doubled in 10 years.
But don’t tell that to Murphy. Hospitals lose about 60 cents on every dollar of Medicaid service, the hospital CEO says. “The fact that we’re getting more Medicaid patients to take care of, and on every one of them we have financial challenges associated with that care — it really isn’t a windfall for us,” Murphy says. “In fact, it’s a greater economic burden.”
While this year’s budget may be back in balance, the hospitals are gearing up for a long-term fight. They want the tax ruled invalid — a move that could take the fight from the capitol to the courtroom.
Thursday, 10 December 2015
State Highlights: Health Data From 3 Medi-Cal Providers Faced Security Risks; Conn. Legislators OK Budget Cuts With Big Hit For Hospitals’ Medicaid Funding
Tuesday, 8 December 2015
How stressful is medical training? So bad that in a class encouraging medical students to express emotion by drawing comics, nearly half depicted their supervisors as monsters.
“In their attempts to make meaning of medical training through images and words, students imagined the workplace as dank dungeons; portrayed patients as ghosts that haunted physicians who had treated them impersonally; represented supervising physicians as fiendish, foul-mouthed monsters; and depicted themselves as sleep-deprived zombies walking through barren post-apocalyptic landscapes,” according to a new article in the Journal of the American Medical Association written by Daniel R. George and Dr. Michael Green, who teach the “Comics in Medicine” class at Penn State College of Medicine.
In one particularly harrowing image, they wrote, a student “depicted his supervising physician screaming at the medical team, causing one intern to urinate herself moments before having her head bitten off for possessing too little information about a patient.”
While the Penn State article encompassed only the 66 students who have taken the humanities class since 2009, a large study in the same annual medical education issue found that nearly one-third of more than 17,000 medical residents in 31 studies screened positive for depression or depressive symptoms. That rate is higher than that for either medical students or practicing physicians who have finished their training, and substantially higher than the rate for the general public.
The study by researchers from several leading medical schools, including Harvard, Yale, and Cambridge in England, added to a body of work showing that the stress of training can cause depression. And it’s not just the doctors themselves who suffer – patients should worry, too. Depression in residents “has been linked to poor-quality patient care and increased medical errors,” the researchers note.
The two studies together demonstrate that something is wrong with the training system in general, University of Nevada Medical School Dean Thomas Schwenk says in an accompanying editorial.
“The profession purportedly recognizes the importance of health and wellness,” Schwenk wrote, “but the value system of the current training environment makes clear to residents the unacceptability of staying home when ill, of asking for coverage when a child or parent is in need, and in expressing vulnerability in the face of overwhelming emotional and physical demands.”
A big part of the problem is that medicine has long been taught by treating underlings harshly – which has been considered acceptable because a mistake could cost a patient her life.
“People treat people like they were treated,” said Green, a physician and professor of internal medicine at Penn State, in an interview. “This is how I did it and I’m OK, so I’m going to do it to you and you’ll be OK.”
But medicine itself has changed, Schwenk said in an interview, and that compounds the problem. “My era (the 1970s) came away with very strong role models and people who were incredibly influential,” he said. “Today everyone is so frantic” with patients moving in and out of hospitals faster and many more strict protocols for patient care. That leaves little time or space for more benevolent types of supervision and teaching for doctors-in-training.
So what would help?
Schwenk says it’s time for the pendulum to swing back toward more personalized training after medical school. “There’s got to be a shift back toward dedicated teaching and mentorship,” he said. “We’ve lost that because of the craziness of the (health) system.”
Doctors who train other doctors also need to practice what they preach, he says. “We don’t teach in ways that encourage wellness and good mental health and coping mechanisms.”
Green says the system also needs to be geared toward stopping the abuse of medical students and residents by professional superiors.
“There has to be a message that this is not OK and there will be consequences for treating people badly,” he said.
But both doctors said they hope that bringing more visibility to the problem could help lead to needed changes. Said Green: “My hope is it’s getting better because we’re much more sensitized to these issues.”
Monday, 7 December 2015
Cigna CEO David Cordani says the individual market created by the 2010 health law would be better off if insurers were given more flexibility in designing coverage, as well as a more compressed, focused open enrollment period.
Just days after UnitedHealth Group’s CEO said their move into the new marketplace was a mistake, Cordani reaffirmed that Cigna remains committed for 2016, although the firm is so far losing money on that business.
Cigna has a small share of the health law market with only 230,000 individual customers this year. But that could grow rapidly if a $54 billion purchase bid by insurer Anthem wins federal approval because Anthem is big player in the individual market. The deal is one of two giant mergers in the works, with Aetna also working to get approval to buy Humana.
If Cigna’s deal is approved, Cordani is expected to remain with the new company as president and chief operating officer. He sat down with KHN’s Julie Appleby last week to discuss the marketplace. This interview has been edited for length.
When looking at the merger, many have asked how can having fewer insurers competing be good for consumers?
When you look at Cigna and Anthem, we are amazingly complementary. Cigna’s strength is for employers … we have unbelievably diverse global set of programs. Anthem is a strong U.S.-based corporation [with] a history and focus really around the individual market and small employers in the states it operates in. We were not historically in the individual market. We’re actually going to create more choice than less. We will be able to take Anthem’s individual infrastructure beyond the 14 states [in which it now operates].
We’ll take their leading Medicaid program and our leading Medicare program and put them together to design solutions for the dual-eligible population. In terms of employer marketplace, we will be able to bring population health and management programs to their employer programs and help expand the geographic footprint.
UnitedHealth’s CEO last month said the insurer is losing hundreds of millions of dollars on its individual insurance market business and hinted it might pull back from the market in 2017. While Cigna is smaller in that market, did you lose money or make money on Affordable Care Act business in 2014 and 2015?
When the law put in place the exchanges, we took a bit of a different public position than many of our competitors. We saw the exchange marketplace as a potentially attractive long-term viable market. We also said we viewed 2014, 2015 and 2016 as Version 1.0 of that market and that it would take those three years for the market to shake itself out. We said from day one we didn’t expect to make money on it. We didn’t make money on it in 2014 and we aren’t making money on it in 2015.
Two of the reasons United gave for the losses were people moving in and out of the market and higher costs for people who signed up after the official three-month open enrollment period closed. [There are a number of special exemptions that allow sign-ups during other times of the year.] How could the law be tweaked to lessen those concerns?
Societally, we are just starting to understand how the market is operating. What is the other market with some similarity? Medicare Advantage [the private alternative to traditional Medicare]. It has a one-time limited enrollment period [that is shorter than the ACA] — I think that’s a good thing. Compress the enrollment period, focus it and have a limited number of exceptions.
Secondly, [provide] more flexibility on how [insurers’ provider] networks are designed.
What Medicare Advantage shows us is by offering more choice, and choice is not necessarily different names of insurers, but benefit designs and network configurations, you get the right choice for you … as opposed to socializing things down.
[The market] has to also have a real focus on transparency [for consumers]. It can have more choice aided by transparency [and] network visibility for individuals to understand what they are buying before they sign up.
Only about 40 percent of the people eligible to enroll have — and they’re mainly concentrated in the income levels with the highest subsidies. What can be done to encourage more people to enroll?
You have to ask the consumer why they’re not enrolling. There’s a perceived affordability challenge. Perception is reality.
If [insurers] are allowed more flexibility in benefit and network configuration, we’re probably going to get solutions that are much more relevant to a part of the population that is not buying.
How would that work? Would you set higher deductibles to get lower premiums?
If you have an individual with a chronic disease, say asthma, you can have a program that is passive: if they want to enroll in a care management plan, they can. Or they can be incented to enroll. Or you can have a plan that is binary: If [you] have that [condition] [you] have to be in that [care management] program. Those are all choices. What we know is if [a patient is] asthmatic and more actively managed, the health outcomes and therefore the affordability can be quite different. This is a case where if you have a chronic illness, you need to be in a management program. We know the quality outcomes will be better and cost outcomes will be more sustainable.
In late December, Cigna will stop paying brokers commissions if they sell gold-level individual plans, which cover more costs than do the less expensive bronze and silver level plans. What is Cigna’s concern with gold products?
Adverse selection. [It’s not that policyholders] are necessarily older or sicker. The whole way the benefits are configured and the way marketplace is working — the performance of those plans — is much less reasonable than all the other plans.
Either there will be more flexibility to configure them in a way to make them sustainable or there won’t be gold plans.
So is Cigna staying in the market?
We’re in for 2016.
How about 2017?
We haven’t made a comment relative to 2017. We view 2014, 2015 and 2016 as Version 1.0.
Saturday, 5 December 2015
Anthem-Cigna Merger Closer To Finish Line After Shareholder Vote But Regulators Still Need To Sign Off
State Highlights: Quarantine Questions Continue; Californians Split On Whether People In U.S. Illegally Should Get Subsidized Health Care, Poll Finds
Friday, 4 December 2015
Thursday, 3 December 2015
State Highlights: Fla. Regulators Publicly Mull Proposed Mergers of Insurance Giants; Will Calif. Budget Surplus Zap Tax That Funds Low-Income Health Care?
Wednesday, 2 December 2015
The rate of avoidable complications affecting patients in hospitals leveled off in 2014 after three years of declines, according to a federal report released Tuesday.
Hospitals have averted many types of injuries where clear preventive steps have been identified, but they still struggle to avert complications with broader causes and less clear-cut solutions, government and hospital officials said.
There were at least 4 million infections and other potentially avoidable injuries in hospitals last year, the study estimated. That translates to about 12 of every 100 hospital stays. Among the most common complications that were measured — each occurring a quarter million times or more — were bed sores, falls, bad reactions to drugs used to treat diabetes, and kidney damage that develops after contrast dyes are injected through catheters to help radiologists take images of blood vessels.
The frequency of hospital complications last year was 17 percent lower than in 2010 but the same as in 2013, indicating that some patient safety improvements made by hospitals and the government are sticking. But the lack of improvement raised concerns that it is becoming harder for hospitals to further reduce the chances that a patient may be harmed during a visit.
“We are still trying to understand all the factors involved, but I think the improvements we saw from 2010 to 2013 were very likely the low-hanging fruit, the easy problems to solve,” said Dr. Richard Kronick, director of the federal Agency for Healthcare Research and Quality, or AHRQ, which conducted the study.
The Obama administration has been focusing on lowering the rates of medical infections and injuries as it tracks a slew of patient safety initiatives created by the 2010 federal health law. Those include Medicare penalties for poor-performing hospitals, wider use of electronic records to help track patient care and prevent mistakes, and grants to collaborations of medical providers formed to improve the quality of patient care and identify the best ways of addressing each type of problem.
The AHRQ report calculated national rates for 27 specific complications by extrapolating from 30,000 medical cases that officials examined. Decreases in infections, medicine reactions and other complications since 2010 have resulted in 2.1 million fewer incidents of harm, 87,000 fewer deaths and $20 billion in health care savings, the report concluded.
“Those are real people that are not dying, getting infections or other adverse events in the hospital,” said Dr. Patrick Conway, chief medical officer for the Centers for Medicare & Medicaid Services.
Some of the most significant progress was made in lowering the number of infections from central lines inserted into veins — down 72 percent from 2010. Medical researchers have proven that these infections can be virtually eliminated if doctors and nurses follow a clear set of procedures.
Infections from urinary catheters decreased by 38 percent and surgical site infections dropped by 18 percent. In all three cases, the reductions exceeded the goals set by the administration. Conway noted that hospitals had a financial motivation to cut these infections as they are used to determine whether hospitals get Medicare bonuses and penalties each year.
However, hospitals have not made headway in trimming the numbers of falls or pneumonia cases in patients breathing through mechanical ventilators, the report found. And the rates of adverse drug reactions and complications during childbirth were higher than what the administration estimated they should be for 2014.
Conway said that complications are difficult to address because they involve tradeoffs that can cause other problems. For instance, he said, hospitals have to balance efforts to reduce falls with the need to help unstable patients improve their ability to walk. “We’ve got to work with providers to figure out what’s the sweet spot that can keep mobilization occurring but decrease the rate of falls,” he said.
Even though overall complication rates were flat, the report found that some types of injuries became less common in 2014. One was the number of blood clots that form after surgery and travel to the lung; those rates dropped by 30 percent in a year.
Maulik Joshi, an executive at the American Hospital Association, predicted that complications will become even rarer in future years. “Hospitals are working on projects that are just not reflected in these data points,” he said.
But a few conditions became more prevalent in 2014. Infections from methicillin-resistant Staphylococcus aureus bacteria, known as MRSA, increased by 55 percent to an estimated 17,000 incidents last year. The number of times a catheter punctured a femoral artery during an angiography increased by 25 percent to 74,000, the report estimated.
“We think we addressed a lot of the areas where there was a strong evidence base on how to improve patient safety,” Conway said. “We’ll now have to tackle that next wave that has multiple causes.”