Sg2 Commentary of Tom Daschle's Book

There was an excellent commentary of Tom Daschle's book posted by Dr. Edward Winslow on the Sg2 Website (free registration required) this week.

Normally, the book of any politician is of minimal interest. However, given that Tom Daschle will be heading HHS and his book's co-author will likely be deputy director, this book may give us a sneak peek of what US healthcare will look like in the coming years.

Here is the first paragraph of Dr. Winslow's commentary:

In February 2008, former US Senator Tom Daschle (D-SD) published Critical: What We Can Do About the Health Care Crisis (Thomas Dunne Books 2008). In November, President-elect Obama selected Daschle to head the Department of Health and Human Services. He also proposed that Jeanne Lambrew (Daschle's co-author) be the deputy director. As HHS Secretary Daschle will be a powerful influence in health care for at least the near future. Because of this, prudent Sg2 members and staff will need to develop some familiarity with the ideas in his book. Any reform plans will of course need to pass both houses of Congress and the desk of President Obama. However, if the proposals in this book are realized, we will see some significant changes. Of particular interest to our members are:

• A larger federal health bureaucracy with a larger role in care decisions
• Limitations on the use of medicines and technologies that will be reimbursed
• Greater uniformity in health insurance coverage

Readers of this blog are strongly encouraged to go to this article at the Sg2 Website where they will also find commentary of how these changes may impact those of us that work in healthcare.

Sg2 markets itself as a healthcare intelligence company. Registered users of their website will find a wealth of other resources covering various service lines. I recommend you register with your work email. If your organization happens to have a relationship with Sg2, you will also gain access to other resources normally restricted to the public.

Proposed Indiana Law Mandates Hospitals to Offer Pneumococcal and Influenza Immunization.

What's the point?

A bill introduced 1/16/08 in the Indiana House of Representatives (and referred to the Committee on Public Health) requires all hospitals to offer immunization for influenza and pneumococcus. The current text of the proposed bill is as follows:

SECTION 1. IC 16-21-7.7 IS ADDED TO THE INDIANA CODE AS A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE JULY 1, 2009]:
Chapter 7.7. Immunizations for Elderly Patients Admitted to Hospital
Sec. 1. This chapter applies to a hospital patient who:
(1) has been admitted to a hospital; and
(2) is at least sixty-five (65) years of age.
Sec. 2. For the period beginning September 1 and ending April 1 of the following year, a hospital shall offer to immunize a patient described in section 1 of this chapter against the following:
(1) Influenza virus.
(2) Pneumococcal disease.
Sec. 3. A hospital licensed under this article shall adopt an immunization policy concerning influenza and pneumococcal disease that includes the following:
(1) Identification of patients who are at least sixty-five (65) years of age and other patients the hospital determines are at risk.
(2) A procedure for offering the immunizations described in section 2 of this chapter upon the admission or discharge of a patient described in subdivision (1) for the period beginning September 1 and ending April 1 of the following year.
(3) A procedure for providing a patient or the patient's guardian with information describing the risks and benefits of the immunizations.
(4) A standing order policy approved by the hospital's medical director or other appropriate physician that includes an assessment for contraindications.
(5) A system for documenting:
(A) the administration of an immunization;
(B) medical contraindications;
(C) patient refusals; and
(D) any postimmunization adverse events.
Sec. 4. The state health commissioner may waive any of the requirements of this chapter if there is a shortage of either of the immunizations specified in section 2 of this chapter.

What's the point of introducing legislation on a topic that is already "mandated" by CMS? Given the hospital industry's acceptance that future reimbursement is going to be tied to performance on publicly reported measures (which includes immunizations), hospitals have been trying to increase their performance on these measures for several years.

CMS's Value Based Purchasing program will decrease the reimbursement of poorly performing hospitals. Thus there is both reward and punishment built into CMS's mandate for immunization.

Despite this motivator, a quick scan of how a few random Indiana hospitals are performing with this measure is surprisingly disappointing. Many hospitals successfully offer to immunize eligible patients less than 80% of the time. Hopefully, these hospitals have started a PI project to address their underperformance in this measure.

Along comes this proposed law to require hospitals to offer immunization to patients older than 65yrs. With the law comes no incentive or consequence for noncompliance. Will hospitals now suddenly feel even more compelled to offer immunizations? Not likely. If money and public reporting is not going to motivate a hospital to offer immunizations to their patients, I doubt a law with no consequence will do anything.

If this law passes as it, it will be an incredible waste of time. All that will happen is that hospitals will write a policy, file it, and get on with their day to day tasks. It is not likely that this bill in its current form will change or improve anything.


Random Indiana Hospital Performance
January 2007 to December 2007
Pneumonia Patients Given Influenza Vaccine:
100.0% COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY,
98.51% National Top 10%,
97.09% REID HOSPITAL & HEALTH CARE SERVICES INC, IN
95.46% COLUMBUS REGIONAL HOSPITAL, IN
91.84% PARKVIEW HOSPITAL,
91.05% MAJOR HOSPITAL, IN
90.30% UNION HOSPITAL, INC, IN
86.17% BALL MEMORIAL HOSPITAL INC, IN
84.62% COMMUNITY HOSPITAL,
83.58% ST FRANCIS HOSPITAL -INDIANAPOLI, IN
83.33% MARION GENERAL HOSPITAL, IN
83.33% HENDRICKS REGIONAL HEALTH, IN
81.89% National Middle 50%,
81.82% RIVERVIEW HOSPITAL, IN
81.16% BLOOMINGTON HOSPITAL, IN
79.00% Indiana State Average,
74.29% HENRY COUNTY MEMORIAL HOSPITAL, IN
68.38% ST VINCENT HOSPITAL & HEALTH SERVICES, IN
58.07% CLARIAN WEST MEDICAL CENTER,
56.00% HANCOCK REGIONAL HOSPITAL,
55.86% National Bottom 25%,
50.00% WHITE COUNTY MEMORIAL HOSPITAL, IN
47.06% CLARIAN HEALTH PARTNERS, INC D/B/A METHODIST,IU,
37.50% WESTVIEW HOSPITAL, IN
*Data from www.whynotthebest.org on 1-24-09

Obama's Agenda for Healthcare

Over the past few months, the US Senate Finance Committee, CMS, and Tom Daschle have all made statements or released papers describing a future vision for healthcare reform.

President Obama's position was recently posted at http://www.whitehouse.gov/ (after his administration took over the site on Tuesday). The agenda focuses on increasing the number of people with health insurance, but is lacking in commitment to control cost or increase the quality/reliability of healthcare.

In fact, the only statement related to healthcare quality is that they will: Require hospitals to collect and report health care cost and quality data.

It will be interesting to see how this agenda mixes with CMS's strong intentions to proceed with Value Based Purchasing.

Mandatory MRSA Reporting in Indiana?

Last Friday (January 16th) Indiana Representative Cynthia Noe (District 87) introduced legislation (House Bill 1539) which calls for mandatory public reporting of hospital MRSA rates. The current text of the bill is as follows:

SECTION 1. IC 16-21-2-17 IS ADDED TO THE INDIANA CODE AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY 1, 2009]:
Sec. 17. (a) As used in this section, "methicillin resistant staphylococcus aureus" means the strain of staphylococcus aureus bacteria, also known as MRSA, that is:
(1) resistant to oxacillin or methicillin; and
(2) identified according to the Clinical Laboratory Standards Institute's Performance Standards for Antimicrobial Susceptibility Testing.
(b) Each hospital shall develop a plan to reduce the incidence of persons contracting the methicillin resistant staphylococcus aureus infection at the hospital. The plan must include the specific strategies, patient screening practices, and infection control practices that the hospital will implement to reduce the incidence of methicillin resistant staphylococcus aureus infections.
(c) Before January 1, 2010, each hospital shall submit a plan prepared under this section to the state department. Each hospital shall submit an updated plan to the state department biennially.
(d) Before March 1 of each year, each hospital shall submit to the state department a report of the methicillin resistant staphylococcus aureus infection rate at the hospital during the previous year in a form determined by the state department.
(e) Information submitted to the state department under this section is a public record.

Although transparency in healthcare is a good thing, I don't think this legislation will accomplish much beyond creating a lot of busy work for hospitals. The resulting data will be of questionable value.

• The information submitted to the State Department of Health will be a public record.
• However, will the State Department of Health have the resources to crunch the numbers in a way that will allow for fair comparisons between hospitals? The financial impact statement for this bill has already been published. It says that this bill is not expected to have a financial impact on the ISDH. What that tells me is that there is no intention to create a system to risk-adjust the rates. In other words, it is the raw data that the public will have access to.
• How will the hospital know if the MRSA infection was pick up in the hospital or before the patient entered the hospital? Test EVERYONE upon admission to a hospital? Who will pay for that?
• What is the purpose of requiring all hospitals to submit an infection control plan to the ISDH? Will anyone read it? Will there be consequences for a hospital submitting a crappy plan? What if a hospital does submit a lame plan? Who's to say that it is lame? Who has the authority to send it back to the hospital for improvement? Ultimately, what's the point?

An alternative to the proposed legislation may be:

• Rather than reporting MRSA data to the state, why not require all Indiana hospitals to participate in the MDRO module of the CDC National Healthcare Safety Network (NHSN). Thus, all hospitals will be reporting data in a consistent method and contributing to a national surveillance database. One of the stated purposes of the NHSN is to "provide facilities with risk-adjusted data that can be used for inter-facility comparisons and local quality improvement activities." The problem with this is that facility level NHSN data is confidential and not available to the public. However, it is better to collect data that has a purpose (ie, for the CDC NHSN) than collect data that has questionable purpose (ie, for ISDH). Either way, facilities become aware of their own MRSA rates. By participating in the NHSN, the data becomes useful to the hospital.
• Rather than having hospitals submit MRSA control plans to ISDH every 2yrs , why not change 410 IAC 15-1.5-2 (the Infection Control section of the state regulations for hospitals)? Sec 2(b) currently says "There shall be an active, effective, and written hospital-wide infection control program. Included in this program shall be a system designed for the identification, surveillance, investigation, control, and prevention of infections and communicable diseases in patients and health care workers." Why not add a subsection here to say that the written plan must specifically include the surveillance, internal reporting, control, and prevention of MRSA? This way, all hospitals will have an opportunity to show the ISDH the effectiveness of their MRSA control plan during the annual licensing survey. Poor or non-existent MRSA control plans will result in citations.

These two alternate ideas will accomplish what Indiana Representative Noe intended with her legislation but in a manner that will produce less "busy work" and more useful information for the purpose of quality improvement.

CMS Releases its Roadmap for the Future

On Friday afternoon (Jan 16th), CMS released a set of documents to the public and policymakers that outlines its current healthcare reform programs, what it intends to do over the next 3-5yrs, and what it needs (from the US Congress) to accomplish it.

The press release was sent out via email and not yet (as of Jan 18th) posted on the CMS website.

Documents posted:

• Roadmap for Value-Based Purchasing
• Resource Use Measurement Plan
• Quality Roadmap Overview
• Qualty Measures Development Overview
• PAC Executive Summary Report
• PAC Full Report

All of these documents can be found here: CMS Quality Initiatives Information

The Roadmap for Value-Based Purchasing is an interesting read for anyone wanting to become familar with all the various VBP transformation efforts and demonstration projects that CMS has ongoing. CMS clearly states that VBP will extend beyond hospital acute care and into physician services, nursing homes, ESRD, and home health. This document outlines the work that has occured so far and the plan for each service category for the next few years.

The following are notes and comments from reviewing this document:

• CMS has an internal workgroup developing "resource use measures". Two measures that it identified for potential future use are imaging efficiency measures and hospital readmission rates for certain conditions. The readmission rate is not a surprise since this already being posted on the hosptial compare website. However, the imaging efficiency measures appears to be relatively new.
• The hospital VBP plan has already been submitted to congress.
• The physician services VBP plan will be submitted to congress no later than May 1, 2010.
• CMS acknowledges that its Part A and Part B payment structure creates artificial silos in the healthcare system and need to be broken down.
• CMS states that physicians and providers should be "jointly accountable for the care they provide, but also should be able to share in any resulting savings. This could include actions by CMS to revise the physician self-referral regulations."
• CMS is starting to demonstrated the level of transparency it is willing to go to. In this past year, CMS has tagged 52 nursing homes (4 in Indiana) on its nursing home compare website as "chronic under-performers". Using surprisingly strongly language, CMS states that it does this to "...encourage these facilities to transform themselves into environments of quality care, or turn themselves over to a management team that would do so."

Are you ready for 10-1-2013?

HHS today released the final code set for ICD-10 - compliance date set for October 1, 2013.

The following are some interesting points from the press release:

• ICD-9 contains 17,000 codes.
• ICD-10 contains 155,000 codes.
• HHS received over 3,000 comments concerning the ICD-10 proposed rules.
• Bowing to requests from commenters, HHS pushed back the compliance date by 2yrs from the proposed rule to the final rule.

The press release can be found here.

Those of us in healthcare quality that run reports based on ICD-9 CM codes will have to overhaul our scripts, programs, and definitions to prepare for this. I'm certainly glad that HHS gave us another two years for the changeover.

Hopefully the private insurance carriers will convert to ICD-10 at the same time. Otherwise, we'll have the same nightmare as when MS-DRGs came out for Medicare but private insurance was still using the the old DRG grouper.

Tom Daschle's comments about US Healthcare

Click here to see video_


Summary of Comments:

• A long way to go to improve US Healthcare
• "US Best Healthcare System" is a myth
• Value = (Access + Quality) / Cost
• Healthcare is a pyramid: bottom is wellness promotion; top is the most "sophisticated technological applications of healthcare".
• Every other society starts at the bottom and work their way up until the money runs out.
• America starts at the top and works its way down until the money runs out.
• Thus we pay a whole lot more.
• We don't make good managers of our healthcare system.
• We need to delegate out the managerial responsibility of healthcare as we delegated out the responsibility of our monetary system to the Federal Reserve over 100yrs ago.
• 45% of people in the us get their healthcare from a government driven system; 55% from private sector.
• Congress should not decide health policy just as Congress should not decide interest rate policy.
• We need transparency in healthcare.
• 100k people die every year due to medical mistakes.
• We don't use "standard of care" in healthcare.
• "We have a 19th century administrative room but a 21st century operating room"
• We need to bridge the gap with IT.
• We need payment reform.
• We currently reimburse by procedure; we need to reimburse by episode.

Given that Tom Daschle will be the person driving the direction of healthcare reform, there is a heck of a lot of people examining every comment that he makes. This is my take of his direction based on these comments: 1) Emphasize wellness; 2) Take healthcare policymaking away from congress; 3) Continue to increase transparency in healthcare; 4) Change reimbursement from procedure to episode.

Note that this video was recorded on June 17, 2008.

Indiana House Bill 1237 - Hospital Charges Resulting from Medical Errors

First reading of House Bill 1237 was this morning (1-12-09). It was then referred to the Committee on Family, Children, and Human Affairs.

The bill seeks to prevent hospitals from knowingly billing patients for charges that are the consequence of medical errors.

The following is the current text of the bill:

IC-16-21-2-17
Sec. 17. (a) As used in this section, "harm" means the temporary or permanent impairment of a body function or structure that requires additional intervention for the patient, including an increase in monitoring of the patient's condition, a change in therapy, or active medical or surgical treatment.
(b) A hospital may not knowingly collect or attempt to collect from a patient, the patient's estate, or the patient's family the payment of a charge for medical services or products that are required as the result of a medical error or event if:
(1) the medical error or event resulted in significant harm or death to the patient;
(2) the medical error or event occurred in the hospital; and
(3) the medical error or event occurred as the result of the negligence or lack of reasonable care by:
(A) the hospital;
(B) an agent, a servant, or an employee of the hospital;
(C) an independent contractor working on behalf of the hospital; or
(D) a physician or other health care provider who has privileges to perform medical services at the hospital.

This is probably the bill that will generate the most debate and scrutiny from the hospital associations. I agree with the philosophy but the execution of the bill as currently written will be quite difficult. If this bill passes, it will be interesting to compare its final form with the current text.

Indiana Senate Bill 0349

A list of bills introduced this year is posted on the state website. You can go there directly from here.

Senate Bill 0349 is amusing. It seeks to insert the following text into IC-16-28-1-13:

(e) Before an employee of the state department, whose job duties include inspection of health facilities in a consistent manner, may inspect a health facility, the state department shall provide appropriate and uniform training to the employee.

Is this Indiana moving forward....or catching up with the other states?

The WHO Campaign for Safe Surgery turns into "The Sprint"

• On June 25, 2008 the World Health Organization launched its "Safe Surgery Saves Lives" campaign.
• On December 20, 2008, Don Berwick calls upon all hospitals participating in the IHI 5 Million Lives Campaign to also participate in "The Sprint" by adding "one more change at a breathtakingly short time" - "adopt and use the WHO Checklist in at least one OR in every hospital in the next 90 days."
• The Indiana Hospital Association recently posted on its "Patient Safety Update" webpage that it is supporting the campaign. "To participate, hospitals need only test the list in one operating room, by one surgical team, one time before April 1." It also says that Indiana is only one of a few states to have committed to testing the checklist.

The scope of the WHO's Checklist for Safe Surgery is broader than the Joint Commission's Universal Protocol to Prevent Wrong Site, Wrong Procedure and Wrong Person Surgery (tm).

Joint Commission's Universal Protocol: Universal Protocol

WHO's Checklist: WHO Checklist

WHO's website (with additional tools and resources): WHO Safe Surgery Website

IHI Campaign website: IHI Campaign Site

How long do you think it will be before the Joint Commission starts to adopt elements of the WHO's checklist?

HHS Releases 5-Year Plan to Decrease HAIs.

Yesterday the HHS released their 5yr plan to address hospital acquired infections. There is a comment period for this plan. It closes on Feb 6, 2009.

The press release is here: HHS HAI Press Release
The executive summary is here: HHS HAI Executive Summary
The contents page is here: HHS HAI Contents Page
Comments can be sent to (until 2/6/09): HAIComments@hhs.gov

The following excerpts are from the "Incentives and Oversight Group" section. It clearly shows the continuation of pay-for-performance, transparency, and public accountability:

Priority Recommendations of the Incentives and Oversight Group:

• Improve regulatory oversight of hospitals and CMS oversight of the hospital accreditation program by refining the current method of measuring Accreditation Organization performance, enhancing surveyor training and tools, and adding sources and uses of infection control data.
• Continue to incorporate measures of infection prevention and outcomes into Hospital Value-Based Purchasing (VBP) Plan methodology through implementing performance-based payment for hospitals, including measures of infection prevention and outcomes as a basis for payment.
• Expand measures in CMS Hospital Compare which improves the quality and transparency of hospital care by increasing public accountability and provides consumers access to important hospital quality of care measures.

The following recommendations would further strengthen the commitment to quality in the prevention of HAIs:

• Require that a hospital ensure that their infection control program follows currently recognized standards of practice as established by national organizations.
• Require that the infection control program be an integral part of the hospital’s quality assessment and performance improvement (QAPI) program. While the current Infection Control CoP does require that the hospital-wide quality assurance program address the problems identified by the infection control officer, this revision would more directly link the Infection Control CoP with the equally important QAPI CoP and would require hospitals to pursue a more proactive and innovative approach to infection control through their ongoing QAPI program.

Recommendations on how the Hospital VBP Plan methodology could incorporate measures of infection prevention and outcomes:

• Individual measures of infection prevention and outcomes, specified elsewhere in this report, could be scored for hospitals as part of performance assessment.
• Individual infection measure scores could be aggregated into a rollup infection measure for hospitals.
• Individual infection measure scores or a rollup infection measure could be aggregated into a roll up patient safety domain, which could be included in hospitals’ total performance scores. Thus, hospitals’ financial incentives would depend, in part, on their performance on measures of infection prevention and outcomes.
• Scores for individual measures, roll up infection measures, and the roll up patient safety domain could be reported on Hospital Compare as an infection scorecard for hospitals.

Each year, CMS will continue adding additional measures to Hospital Compare. These enhancements are part of HHS’ ongoing commitment to increased healthcare transparency. CMS is adding 13 new measures for the FY 2010 program, and retiring one existing measure. The inclusion of these additional measures will encourage hospitals to take steps to make care safer for patients.