The inaugural post of Pattern Analysis described the “new geography” of the 33 medical schools that between 2002 and 2013 had been accredited by either LCME (15) or AOA/COCA (18) to recruit and enroll medical students. The second post raised the question, Where will the clinical faculty necessary to teach the students in these new schools come from? This is a particularly tangled problem because nearly all of these schools have declared their mission to be the training of primary care physicians to practice in underserved rural and urban areas. Yet it is an accepted article of faith, nationally, that there is already an insufficient supply of practicing primary care physicians. Recruiting significant numbers of them to teach in new as well as existing schools of medicine will further reduce the amount of primary care physician time available for patient care.

The interesting issues don’t stop there. An additional 15 allopathic schools have been proposed since the end of December 2011 and 12 “new and developing” osteopathic medical schools currently are listed by AOA/COCA. None of these schools have developed to the point where the accrediting bodies will permit any of them to recruit or accept students. To be sure, many of them are more than mere proposals, and the total number may include a passing fancy (or fantasy) or two. What I try to do here is to identify the purposes and forces driving the proposals and to associate the putative schools with them. That analysis will lend some clarity to the question of whether any of these proposed schools is likely to become an accredited school in a reasonable length of time, say before 2020.

The data analyzed here come mainly from two sources: the AAMC-CAS newsletter assembled and issued by Tony Mazzaschi; and the AOA/COCA report “New and Developing COMs and Campuses” updated through March 31, 2013. These sources were supplemented by my personal knowledge of California, Texas, and Virginia institutions in particular.

Excepting the fact that most of the proposed schools are located in the southern half of the country, there is no national pattern as there is with the newly accredited schools. The latter tend to be located in rural areas, where there is an acknowledged lack of primary care physicians and consequently an underserved population.

On the other hand, the locations of the proposed schools range from “somewhere in Kansas,” to small towns and cities, to a handful of metropolitan centers, to the established campuses of major university systems, some of which have had branch medical school campuses for years. The geographic distribution of the proposed schools looks like a scatter diagram with a correlation coefficient of zero.

An unusual characteristic of two of the proposed allopathic schools (Palm Beach and California Northstate) is that they are for-profit organizations. Although there is at least one for-profit osteopathic school, LCME has never accredited a for-profit school, but is showing these two schools as being in “Applicant Status. “

Proposed Allopathic Schools

University system development of four-year medical schools either de novo or as expansions of branch campuses: University of California System, Merced; University of Colorado System, Colorado Springs; University of Indiana, Evansville; Louisiana State University System, Baton Rouge (with the Pennington Research Institute) and Lafayette (with University of Louisiana); University of Texas System, Austin and Rio Grande (exact location to be determined); and University of Nevada, Las Vegas.

Other than the Louisiana possibilities, which may be trial balloons in a state that already has three allopathic medical schools, and the Nevada proposal made by a Las Vegas physician member of the Board of Regents, the university system proposals are virtual certainties in five years or less. Colorado is funding the development of the Colorado Springs school at the rate of $3 million per year for the next 10 years. At 40, the Evansville branch of Indiana University School of Medicine is well established. The two Texas schools have university system, state government, and strong private-sector support. The University of California, Merced has a rudimentary administrative organization in place and its development will probably move forward more quickly now that the State’s fiscal difficulties seem to be under control.

Private university and college development of four-year schools: California Northstate University, Rancho Cordova, California (for-profit), a Sacramento suburb; Palm Beach Medical College, Palm Beach, Florida (for-profit); Roseman University of Health Sciences, Henderson, Nevada; University of Incarnate Word, San Antonio, Texas; King College, Abingdon, Virginia; “Local Supporters,” Martinsville, Virginia; Shenandoah University, Winchester, Virginia.

This is a basket of unknowns. As noted earlier, LCME has never approved a proprietary school. Two are proposed and in Applicant Status. Henderson, Nevada, is a suburb of Las Vegas where there is a major branch of the University of Nevada Reno School of Medicine (and a proposal to make it a four-year school) and a Touro University College of Osteopathic Medicine. It seems that it would be difficult to shoehorn another four-year school into this milieu, although Las Vegas has become a metropolis of 2 million people.

Virginia has four allopathic and one osteopathic school now. Three more seems like an over-reaction. Carillon (MD) in Roanoke and Edward Via (DO) in Blacksburg are both responses to perceived unmet needs in southwest Virginia that have continued in spite of targeted efforts since the 1970s by the University of Virginia and Virginia Commonwealth University/Medical College of Virginia to increase the number of primary care physicians in the area. East Tennessee State University’s Quillen Medical School (in Johnson City 25 miles south of the Virginia state line) was also a 1970s response to the same problem in the bi-state area. Shenandoah’s proposal is being evaluated for feasibility. In my opinion, the Martinsville proposal will founder. King College is in Applicant Status with the LCME but may affiliate with East Tennessee.

Texas is an extremely wealthy state, but with seven public and one private medical school and two more public schools under development, it seems unlikely that a small sectarian institution like University of the Incarnate Word can develop a private allopathic school in the shadow of the UT system.

Proposed Osteopathic Schools

Traditionally organized institutions of higher education: Larkin University, South Miami, Florida; Indiana Wesleyan University, Kansas; Missouri Southern State University, Joplin, Missouri; Liberty University, Lynchburg, Virginia.

Liberty University has advanced from “Applicant” to “Pre-accreditation Status” and in all probability will add yet another medical school to Virginia’s five accredited institutions in another two to three years. Larkin became an Applicant in January 2013 and Indiana Wesleyan has been an Applicant since 2008. I would bet on Larkin.

Single purpose institutions: Southern California College of Osteopathic Medicine, Los Angeles; Center for Allied Health Nursing Education, Florida; University of St. Augustine for Health Sciences, St. Augustine, Florida; Homer G. Phillips College of Osteopathic Medicine, St. Louis, Missouri; Monmouth College of Osteopathic Medicine, Monmouth County, New Jersey; Southwestern Pennsylvania (College of Osteopathic Medicine?), Beaver, Pennsylvania; Southern Utah College of Osteopathic Medicine, Cedar City, Utah; Wisconsin College of Osteopathic Medicine, Wausau, Wisconsin.

Forecasting the future for this group of institutions is chancy at best. I would be surprised if half of them were accredited within the next three to six years. Monmouth, Cedar City, and Wausau are the most likely to emerge with accreditation.

How Many Is Enough?

Aside from the question of where the faculty will come from, one might also ask whether a 30 percent increase in the number of schools over 2002 is needed or desirable. The accrediting bodies focus only on quality and assiduously avoid the question of numbers, so any answer will have to come from other sources—political, economic, population health, business. Of course, these disparate sources rarely talk to each other and there is no more a coordinated plan for medical education in this country than there is a plan for how health care can be delivered humanely, professionally, and cost effectively to all.

—James E. Lewis, Ph.D., is an independent consultant to departments and schools of medicine, and teaching hospitals. He served as Deputy Dean for Operations and Vice President for Academic Administration, Mount Sinai School of Medicine and Medical Center, and Senior Executive Officer, Department of Medicine, University of Alabama at Birmingham. His monthly column, “Pattern Analysis,” appears on Wing of Zock. He can be reached at greegmt@me.com.

By Ted James, MD

What does simulation have to do with health care reform? More than you may think.

Health care is undergoing a period of unprecedented transformation, during which simulation has emerged as a powerful tool to ensure patient safety and quality. However, simulation also provides the ability to design and model innovations in health care process, and then study the impact of these innovations in a controlled learning environment prior to wide-scale implementation. It’s an ideal opportunity to simulate processes to help achieve accountable care and high-reliability within a value-driven health delivery system.

One way we use simulation to achieve process improvement is through our mobile, ‘in-situ’ simulation program. We essentially bring the simulation laboratory into the health care facility where scenarios can be performed using actual hospital environments, equipment and staff in order to assess teamwork, efficiency and systems-based factors affecting quality.

For example, our converted ambulance, the “Simbulance,” provides the setting for realistic patient transport scenarios as well as bringing our equipment to area hospitals and other off-site locations. The mobile simulation program is very effective in assessing team response as well as hospital process during emergency scenarios. The results tend to be quite enlightening, especially during the debriefing session when people analyze and reflect on their performance.

Participants typically recognize areas where they can improve efficiency and reduce waste. For example, following one scenario, members of a clinical team realized that some of the same activities being performed were needlessly redundant. They discovered better ways to organize the team and allocate tasks in a way that added value to patient care. In another case, a nurse identified that the procedure kits they were using during a resuscitation scenario could be standardized to streamline care and improve results.  

What we also continually discover in simulation is just how critical team collaboration and communication are to patient care. It’s a little surprising, but most negative outcomes are not the result of technical incompetence or lack of medical knowledge, they are from communication breakdowns or poor team coordination. Therefore, we use simulation to enhance the performance of our clinical teams by designing programs focused on effective clinical communication and inter-professional teamwork. It’s not that we won’t provide technical skills training, but we also go beyond procedural skills and use simulation to help create well-organized, high-functioning teams – which deliver better patient care.

Looking forward, the Clinical Simulation Lab is looking to redesign health care to enhance patient-centered care and value.

Here’s some of what you can expect to see this year and beyond:

• Simulation programs aimed at enhancing the patient experience, reducing patient wait times and eliminating unplanned readmissions to the hospital.
• Programs incorporating human factors and usability testing to optimize the use of electronic health records and new medical technology. We can beta-test new medical devices in simulation to reveal potential hidden problems that may otherwise go unnoticed until used in actual patient care..
•  We are developing  programs to help parents care for children with special medical needs at home.

I’m personally very excited about an upcoming community program where we are going to simulate an emergency room trauma resuscitation following a texting-related car accident. This is part of a community program delivering a message about the dangers of texting-while-driving to local high school students.

The future of simulation in health care is quite promising. We believe that simulation saves lives; and furthermore, that it can help bring about transformations in health care delivery leading to safer, more efficient, reliable systems of patient care.

Ted James, MD, is medical director of the Clinical Simulation Laboratory at Fletcher Allen and the University of Vermont College of Medicine. He is also a surgical oncologist at Fletcher Allen and associate professor at the University of Vermont College of Medicine.

The Clinical Simulation Laboratory provides health care professionals with a comprehensive, practical, and innovative solution to today’s clinical training and health care improvement needs in a safe, convenient, and controlled learning environment.

When Feinberg agreed to serve UCLA as interim CEO several years ago, patient satisfaction scores–of which he was unaware–hovered around 26 percent. Feinberg, a child psychologist, was accustomed to eye-level, intimate conversations with his patients. He began roaming the hospital hallways for a couple of hours a day, talking with patients and their families.

“What I realized after about three months was, although we were ranked number 3 by U.S. News and World Report, no one in the hospital was in charge of care,” he said. “I witnessed unprofessional behavior in a dirty hospital that also served cold, bad food.”

Feinberg set out to change it all: mission, hiring, culture. “We can face every problem if we have the patient facing us and helping us,” he said. Hiring for a customer service orientation and empowering frontline staff meant that anything was possible:

“I tell staff, ‘Make it happen as if each patient is a member of your own family. The only time you’ll get into trouble is when you don’t.’”

The entire organization is now aligned in its belief that it’s important to get patient care right, and that it’s important to track metrics that demonstrate progress, Feinberg said. Results have been impressive: Patient satisfaction scores now hover around 99 percent.

An audience member asked how Feinberg resolves the tension between patient satisfaction and cost. Rather than being a money pit, patient satisfaction efforts are a cost saver, a referral generator, and a gift driver, Feinberg replied.

What’s his next BHAG (big hairy audacious goal) for UCLA? To render hospitals obsolete.

“If people would eat right, quit smoking, use alcohol in moderation, stop shooting one another, and wear seat belts, there would be little need for most of us in this room. My goal is to close all the hospitals,” he concluded.

During any shopping trip, an item found without a price tag seems to be followed inevitably by the old quip that “if there’s no price, it must be free.”

The joke’s ubiquity might speak to an inherently human tendency to simply ignore the cost if it’s not clearly marked—and you’re not the one shelling out. That even appears to apply to health care.

A study conducted by researchers at The Johns Hopkins University School of Medicine and published online April 15 by JAMA Internal Medicine showed that simply displaying the cost of a procedure lowered the rate of test ordering by 9 percent, with no evidence of a corresponding decline in the quality of the care delivered.

“We looked at the number of labs Hopkins had been ordering and we thought to ourselves it seems we’re ordering a lot more labs than needed to care for patients in a safe and high-quality way,” said lead study author Leonard S. Feldman, M.D., an assistant professor of medicine in the school’s Division of General Internal Medicine. “You could order any lab you wanted without any sense of cost to it. It’s like a bottomless cup that you just continue to fill with more and more labs. There are more tests available to us. They come back faster, and others do it for them. It’s almost too easy.”

Over a six-month period, the researchers randomly assigned 61 diagnostic laboratory tests at The Johns Hopkins Hospital for the experiment, displaying fee data for some tests but not for others. The 9 percent occurred for the tests displaying fee data, while those that did not have fee data displayed increased slightly. The research saved the hospital $400,000 over six months.

Feldman said the experiment also reduced costs without placing any new burdens on providers.

“We just reminded them of the costs without adding extra clicks or making their job harder or doing a large educational effort where the gains can go away,” Feldman said. “It reminds providers that there is a cost to doing business, and they should take that into account.”

Feldman said the most savings occurred in the more common tests. In one of the more extreme examples, Feldman said there was “a huge reduction” in orders for ionized calcium tests, which Feldman said were being ordered in many cases “for no reason we could readily ascertain.”

Feldman said the fee data display was becoming a more regular feature at the hospital. Because Hopkins is a teaching hospital, residents are often the ones ordering the tests. Previous studies have shown that younger doctors tend to order more tests than their older counterparts.

“It’s almost too easy these days to order a test. You order it and someone else does it for you. Ordering tests is what we do,” Feldman said. “But residents here are saying it was neat to see the cost. They were open to it and pleased.”

By Ulfat Shaikh, MD

A couple of months ago I drove past fertile vineyards and took in the not-so-sweet scent of dairy farms, en route to a small community hospital in California’s Central Valley. I had been invited to present a continuing medical education session on The Joint Commission’s requirements for clinician evaluation.

As a board-certified practicing pediatrician, I am all too familiar with my own relatively new requirements for re-certification. The American Board of Medical Specialties recently introduced a Maintenance of Certification (MOC) process much more extensive than what was required in the past. I now need to pass a periodic closed book examination, demonstrate ongoing learning and participate in quality improvement projects.

The Joint Commission has its own set of evolving acronyms, OPPE and FPPE, designed to provide oversight for clinicians applying for or maintaining hospital privileges. In 2010, the Federation of State Medical Boards’ Maintenance of Licensure (MOL) process specified that physicians demonstrate continuous professional development in order to renew their medical license.

I am all for greater oversight. Who would want sub-standard care for their patients, let alone for them, their friends and family members.

In an ideal world, this system of monitoring would produce better and safer care and not be significantly burdensome to hospitals or clinicians. However, the current state of clinician evaluation may at best be inadequate and at worst be detrimental to actual value and quality improvements.

There are a number of issues with our current ways of evaluating clinicians. Evidence supporting the effectiveness of MOC in improving clinical practice and patient-level outcomes is starting to trickle in, but is far from conclusive.

Multisource feedback (input from peers and patients) has its own set of limitations in assessing a clinician’s ability to practice medicine. Studies advise exercising caution when using peer and patient feedback since it may be subject to biases. For example, physician assessments are frequently influenced by personal characteristics, rather than by professional performance.

Providing patients reassurance that the clinician or hospital treating them follows certain standards is a worthwhile goal. However, making sure that these plethora of requirements really translate to better, safer and more cost-effective care is an even more worthwhile one.

–Ulfat Shaikh, MD, MPH, MS is director of health care quality at the University of California Davis School of Medicine. She blogs about health care quality improvement at Pulse.

I recently co-organized Millennial Medicine, an international meeting on the future of medical education.  The meeting, the speakers and the comraderie was amazing.  But what happened beyond the room was just as interesting.  Our meeting was livestreamed.  This created a lively back-channel dialog with conversation and sharing.

This isn’t news necessarily. But as someone who spent over a year organizing Millennial Medicine, watching the response beyond the people sitting before me was perhaps the most unexpected part of the day.  Long after the IRL audience had gone home, the sharing continued around the meeting’s hashtag.

It’s becoming obvious that meetings are not just places where people gather, but rather they are emerging global conversations. They are human and emotional spaces.  They are borne of ideas and passion, not buildings and chairs.

Sure, there’s clear value by being in the same room with the speakers. Virtual proximity to speakers has real value but never could’ve been conceived of before the age of near synchronous, global dialog.

I might even venture to add that there can be more value in the back channel with one’s own trusted network that in person with people with whom you might have little connection with.  Communication with the audience during a meeting is verboten – with your network, it’s open season.  As was suggested this week on Twitter, the clatter of laptop keys is the new applause – h/t to Lisa Fields for the lively tech imagery (@practicalwisdom).

All of this raises the question about what constitutes a meeting.

Physician-physician communication sits at the cusp of two generations. There’s the last generation that elects to sit and receive information locally through a crackly PA system. Then there’s the generation that wants to interact globally in real-time with focused, self-selected information relevant to its needs.

The term ‘medical meeting’ will evolve to have more historical meaning.  It suggests that the way doctors once related was episodic and isolated.  We would come, then we would go away.  I’m in, I’m out.  Now we’re engaging, now we’re not.  Until we ‘meet’ again.  Now the meeting and the conversation never really end, and our engagement is increasingly continuous.

While planning this meeting, my mindset for a year was focused on the experience of a couple of hundred people coming into a room.  I have to wonder if our frame of reference of what constitutes Millennial Medicine will change next year.

—Bryan Vartabedian, MD, is a pediatric gastroenterologist at Texas Children’s Hospital/Baylor College of Medicine. He writes the “Socialized Medicine” column for Wing of Zock and blogs at 33Charts.

Debates over who decides research priorities and how; and who decides what research should be funded by the federal government and how, are not new. They reflect competing views on the relative quality, priority, and appropriateness of research undertaken by scientists in this country. Sometimes, the debates veer into perilous territory. You may recall the infamous Golden Fleece Awards, which singled out projects funded by federal dollars as “wasteful” or “misguided.” The National Institutes of Health (NIH) and the National Science Foundation (NSF) — two of the world’s most respected funding agencies supporting a broad spectrum of science and the scientific review process itself — invariably are called to task  during these debates.

Recent activities in the House Science, Space, and Technology Committee raise some concern that Congress may take steps to insert an additional (Congressional) layer of review of research projects funded by the NSF and the National Aeronautics and Space Administration (NASA). A discussion draft of the proposed bill, dubbed the “High Quality Research Act,” suggests that such requirements for additional Congressional review be extended to cover other federal science agencies, including the NIH.

In the simplest terms, this proposed bill would place decisions about the quality, priority, and appropriateness of scientific research into the hands of members of Congress. It positions them to second-guess decisions made by scientists and agencies that have been responsible for advancing incredible discoveries: discoveries that have increased the lifespan of patients with cardiovascular disease, created new life-saving vaccines, practically eliminated deaths from some forms of childhood cancer, and numerous other breakthroughs.

Congressional incursions into ruling on critical areas of research will effectively upend the entire process for identifying and supporting research priorities, which thus far has distinguished the United States as a global leader in research. Certainly, scientific review, like any human endeavor, is not perfect, but let’s look at just one result of the current process, which is founded on partnerships across our federal funding agencies and scientists across the nation.

Dr. Elizabeth Blackburn won the Nobel Prize in Physiology or Medicine in 2009 for her research on telomeres and telomerase, research she conducted on single-celled organisms otherwise known as “pond scum.” This work, evaluated over many years by scientific review, has launched new strategies in treating diseases and conditions such as blindness, cardiovascular disease, neurodegenerative diseases, and cancer. One wonders if Dr. Blackburn’s research on pond scum would have passed muster today with some members of Congress, based on the criteria outlined in the draft High Quality Research Act.

The scientific community welcomes Congress’s commitment to high quality science. We are all accountable to the public for stewardship of their dollars and for providing research in their interest. This requires all of us to do what we do best and work together. Scientists must communicate to Congress and the public the value of science that improves the health and well-being of the nation.

Congress must also do what it does best: to establish policies and resources that sustain funding for high quality science and to trust the scientists and federal funding agencies to assess the quality, priority, and appropriateness of the resulting research.

—Ann Bonham, Ph.D. is Chief Scientific Officer at the Association of American Medical Colleges. She can be reached at abonham@aamc.org.

VIDEO EXTRA:

Vivian Lee, MD, Dean of the University of Utah School of Medicine and CEO of University of Utah Health Care, speaks on the importance of academic medical research and stewardship of national fiscal resources.

In her featured post, Dr. Conroy blogs about the fundamentals of Medicare and provides a financial breakdown of enrolling in Part A and Part B coverage.

From the Review:

For those seeking more info on Medicare and the often-mind-numbingly-confusing array of programs, acronyms, and payment schemes, Joanne Conroy MD’s post offers a simple overview of the program.

Full Health Wonk Review after the jump.

This biweekly edition of health Wonk Review covers the recent news that health care cost inflation has moderated, digs into various aspects of ACA implementation, and provides insights on a couple other timely topics.  Read on!

Health care cost trends are slowing…

First up, Health Affairs’ just-released research indicates the decline in inflation could result in a reduction of $770 billion (yup, that’s “billion” with a B) in public program health care costs over ten years.  

I can hear the cheering…

For those looking for a thoughtful and comprehensive consideration of the sustainability of this trend, consider this post from John Holahan and Stacy McMorrow of the Urban Institute; “All of these factors taken together suggest that a return to a high historic growth rates in health care spending may not materialize….we…are cautiously optimistic.”

John Roehrig is less optimistic, using research into economic cycles and related factors to come to a conclusion that “I don’t think either of these studies suggests that spending growth is likely to remain at the 4 percent levels seen over the past four years. [emphasis added] Some portion of the slowdown is permanent but some will be given back during a recovery.

I’ve reviewed these and several other reports, and my takeaway is guarded optimism.  Sure, the economy reduced demand, but there’s no question there are fundamental changes occurring that are affecting care delivery, pricing, and reimbursement.  

While drug costs are not top-of-mind these days, a group of oncologists is plenty cranky about the cost of specialty meds intended for cancer patients.  David Williams gives us his take, quoting one section of the doctors’ opinion piece: ““In the US, prices represent the extreme end of high prices, a reflection of a “free market economy”.

One cannot talk drugs without talking marketing to docs; Gary Schwitzer has highlighted an innovative marketing approach involving Hooters… If you don’t follow Gary, you should.

One area that researchers are paying close attention to is facility costs; Brad Flansbaum’s entry; Brad discusses the problems inherent in reducing costs in the hospital environment – “Most providers employed by hospitals know the drill: increase throughput, implement regulatory changes, monitor hospital measurement and report cards, and of course, reduce costs.  However, despite the growth of “hospital as laboratory” and rise of the inpatient practitioner, we must face facts.  We receive our salary from the beast we wish to slay.” [emphasis added]

Sticking with hospitals, a recent WSJ opinion piece assaulted Medicare’s new hospital re-admissions reimbursement policy; the John Hartford Foundations’ Chris Langston presents a clear-eyed, point-by-point rebuttal that shows why the program is a necessary and important step to improving health care for older adults. The net? The reduction in reimbursement for re-admitted patients appears to be good policy and will likely drive improvements in patient care and quality. 

Implementing reform

A big part of reform’s implementation involves exchanges; Louise Norris ofColorado health Insurance provides a brief overview of the progress his state has made: “Less than a year after the ACA was signed into law, Colorado began the – often contentious – process of creating the state’s exchange.  They’ve been working on it pretty much constantly ever since. And the result is Colorado’s health insurance exchange is on track to open on time and provide all of the promised services:  small business and individual sales platforms, with an option for employees to select from multiple plan options in the small business exchange.  Jay hasn’t seen data from DC and the other 16 states that opted to run their own exchanges, but guesses they’re also faring relatively well,

Interestingly, the move to electronic health records (EHR) may well lead to higher costs, as providers get better at coding, payers end up paying for more stuff.  That’s one  takeaway from Jonena Relth’s submission on EHR and a recent teleconference on same.

The changes in delivery models may well lead to long-term cost reductions, however patient involvement will be key.  Jason Shafrin’s contribution contemplates the issues inherent ininforming Medicare patients they’ve been assigned to an ACO; many may not know…

Neil Versel has also contributed a piece on consumer awareness – or more accurately the lack thereof.  His piece refers specifically to ignorance about telemedicine, and what the industry must do to reduce that ignorance

For those seeking more info on Medicare and the often-mind-numbingly-confusing array of programs, acronyms, and payment schemes, Joanne Conroy MD’s post offers a simple overview of the program.

Writing at healthinsurance.org, Wendell Potter doesn’t see the possible decision of some large insurers to avoid the exchanges as much of an issue; “The number of insurers that participate in the exchanges will vary from state to state, but there should be no shortage of affordable options available, especially when the subsidies – which will be available only for coverage purchased through the exchanges – are factored in.”  Wendell cites Vermont as an example; there are only two likely participants but both have submitted rates that are quite competitive with current products.

Motivations and motivators

Then there’s the motivation of big health plans and their leaders – can you spell M-O-N-E-Y?  I thought you could…The always-engaged Roy Poses MD has two posts; one discussingUnitedHealth’s CEO, his compensation, and UHG’s rather checkered recent past and issues of quality, physician oversight, and patient safety.  Ouch.  Similar concerns exist regardingAmgen’s executive compensation and their recent legal troubles.  

An interesting perspective on the same issue comes from Jaan Sidorov MD MHSA; Jaan wonders if the policy of “no pay for readmissions” could translate into shoddy care for patients who, despite the best of care, still have to be readmitted; If you had to be readmitted through no fault of anyone, wouldn’t YOU want your doctors to be compensated for taking care of you?

Thanks to Maggie Mahar for her post on breast cancer awareness – an effort that I (and others) think has had some significant negative consequences.  Maggie says: “Could it be that breast cancer arareness has become over-awareness? This isn’t happening in other countries. Then again, we are better at marketing fear than any other country in the world. And the pink ribbon campaign is all about marketing.”[emphasis added]

Side-bar note – I’ve long been a critic of the male version of breast cancer awareness; the prostate cancer scare, those who profit from it, and their well-intentioned but harm-causing supporters.

Research says…

John Goodman thinks a recent analysis of Oregon’s Medicaid program is a damning indictment of Obamacare; “a new study finds that (as far as physical health is concerned) there is no difference between being in Medicaid and being uninsured.”

Ezra Klein has a different take on that study; while there’s no question many health status measures did not differ between the Medicaid insureds and uninsured’s, depression was 30% lower among the insured group.  More significantly Ezra notes a wealth of other research has found Medicaid coverage does tend to improve health status.

Thanks to Vince Kuraitis and Leslie Kelly Hall for their editorial on the “duty to share” patient information with the patient.  In the US and the UK, providers have excessive incentives to “hoard” patient data and insufficient incentives to “share” it.  Consistent with a recently released report in the UK, they authors recommend development of an explicit duty to share patient information and discuss barriers and implications.

from the Work Comp World

WorkCompInsider’s Jon Coppelman thinks Massachusetts’ Governor Deval Patrick’s idea to tax workers’ comp indemnity (wage replacement) benefits.  This in a state where those benefits are already inadequate – at best. 

Bad idea, Your Honor.

Mike Allen alerts workers’ compensation payers to the need to prepare for reform; while PPACA doesn’t specifically address workers’ comp, there are a host of implications – especially for tech platforms.

Today’s tech topic

David Harlow’s piece focuses on Massively Open Online Medicine, showing just how diverse – and informed – HWR contributors are. If health sensors and wearable devices do become prevalent, it will likely take a lot of time – and a lot of change by a lot of people and institutions.

The passage and implementation of the Affordable Care Act means we must increase our efforts in care coordination to provide optimal quality care to all insured patients. Empowered nurses possess highly effective conflict resolution skills and understand the skillful application of nursing ethics which are among the prerequisite skills of nurse advocates working on a strong patient care team. A culture of advocacy and empowerment among nursing students decreases the length of hospital stays and improves patient outcomes overall.

Nurses advocate for patient safety when they coordinate patient care delivered by multiple health care providers. When multiple practitioners provide care for a patient, each member of the team needs access to complete medical information such as tests, procedures, surgeries, consults, and medications to prevent errors caused by practitioner oversight.

Uncoordinated care contributes to fragmentation in patient care and could cause significant risk to patient safety. An elderly person can see up to two primary care practitioners and five specialists within one year. According to the AHRQ 2011 National Healthcare Quality Report, increased care coordination reduces hospitalizations in patients with heart failure, reduces readmissions in patients with mental health conditions, and reduces mortality and dependency in patients with stroke.

Patients seek to be well. Nurses are patient advocates who provide education for family members and home care providers and recommend resources to maintain the patient’s high level of wellness. They inform patients that they have a right to participate in their care, a right to safe care, a right to access care, and a right to be fully informed of all the treatment options available.

Empowered nurse advocates maintain open communications with all members of the health care team. Rather than accept the misconception that nurses are people to whom work is delegated, nurses empower themselves to deliver quality patient care independently and collaboratively as equal members of the health care team. Although nurses continue to provide bedside care and being a calming influence for patients enduring stress of illness, today’s nurses build relationships across the health care team on behalf of their patients.

Nurses understand the important role higher education plays in preparing nurses to be successful leaders and patient advocates working in future health care systems. Because nurse advocacy is one of the basic professional roles and responsibilities, it is woven into the curriculum at American Sentinel University. Patient advocacy, leadership, communication, and building relationships in complex health care environments are essential concepts that are woven throughout our nursing curriculum. Undergraduate and graduate nursing students at American Sentinel University complete their nursing studies in a flexible online classroom environment. They are able to participate in meaningful discussions facilitated by nurse faculty in addition completing to their coursework.

Nursing is no longer simply about sitting by the bedside, holding the patient’s hand and being a calming influence, but about building relationships within care teams so we can deliver patient-centered care. The biggest impact we can have in the future of nurse advocacy and building successful leaders in our nursing programs is through education and communicating our understanding of the role of professionalism in the health care system.

-Dr. Ohmart is the Associate Dean, Simulations at American Sentinel University and is responsible for design and implementations of educational simulations across the University. She can be reached at Gloria.Ohmart@americansentinel.edu

Editor’s Note: This week is National Nurses Week. Learn more about the contributions nurses make to academic medicine, and more about National Nurses Week here.

The Department of Health and Human Services (HHS) released new data on May 8, showing significant variation in what hospitals charge for inpatient services. The release is part of a health care transparency initiative designed to help patients compare charges for common procedures. Increasing transparency is an important step toward effective health care reform, but simply providing data won’t help patients navigate and better understand the complex system used to price and pay for health care services.

To chart a path forward, we must understand how our current system was built and why it is so complicated. Many charges were established before hospitals could accurately assess costs. The assessment has improved substantially, but the payment system formed around hospital chargemasters—extraordinarily lengthy lists (some containing up to 45,000 items) of the costs of every hospital procedure and supply item. While the chargemaster reflects individual item prices, the prices that hospitals are actually paid are largely reflective of the payment rates negotiated by private insurers and the extensive payment rules that Medicare and Medicaid follow.

Medicare relies on a system of centrally administered prices by paying hospitals a flat fee for groups of services that are assigned a relative payment weight, multiplied by a conversion factor, and then adjusted for a range of variations that impact cost of care (such as the regional cost of labor and the costs associated with training residents). Medicaid also uses flat fees for groups of services, per diem payments, or cost reimbursement based on fee schedule unique to the state and the setting in which the service is provided. Commercial insurers apply steep discounts to hospital charges, negotiate rates on contracts irrespective of the charges, or pay flat charges for cases (modeled to some degree off of the Medicare system).

In short, the prospective payment system, flat payment arrangements, and contractually negotiated rates have made hospital billed charges much less meaningful. Therefore, solely making information about charges available to the public does not generally help patients become informed health care consumers.

It is clear that the system is not optimal. It is burdensome for hospitals to manage and update extensive chargemasters. It can be confusing and stressful for patients when they look at charges on their bills, even if they understand that the charges are much higher than the prices they or their insurers will have to pay. Further, billed charges can matter for patients whose insurers do not have contracts based on discounted charges, or who are required to pay coinsurance based on a portion of the hospital bill. While uninsured patients were billed based on the chargemaster in the past, many hospitals now offer means-tested discounts for these patients. Additionally, those patients with very low incomes may receive free care.

So where do we go from here?

Hospitals and health care policy experts are evaluating better ways to price health care services. Academic medical centers, which are responsible for training the nation’s future doctors as well as providing quality care, are committed to transparency and standardizing different cost accounting methods and assumptions used to capture costs across health systems. This is a challenge to all stakeholders in the health care system, including private payers and government health care programs. We all play a role in understanding and reflecting actual costs, as well as in simplifying payment systems and their communication to consumers. We must contain costs together while maintaining the quality of health care we deliver to our nation’s patients.

—Joanne Conroy, MD, is Chief Health Care Officer at the Association of American Medical Colleges. She can be reached at jconroy@aamc.org. Follow her on Twitter @joanneconroymd.