State requiring facilities to participate in system or pay to opt out

Jerry Mitchell
jmitchell@clarionledger.com

Mississippi has begun sending out notices for the nation’s first “pay or play” trauma care system.

Starting Sept. 1, hospitals in must agree to be part of the state’s trauma care system or opt out by paying up to $1.492 million - the estimate it would cost a hospital for that trauma care. The statewide system officially begins Jan. 1.

“I’m proud of our state for stepping up to the front,” said State Health Officer Dr. Ed Thompson. “People are going to be alive five years from now that wouldn’t be if we hadn’t passed this thing.”

Until this change, Mississippi’s voluntary trauma system had been in danger. In 2002, 23 Level III or higher hospitals participated in the system. Now 12 participate.

Thompson said the result is huge holes in the trauma care system for Mississippians who live in east central Mississippi and have no Level III or higher hospital. The same is true, he said, for those living in southwest Mississippi.

The first hour of trauma care is called the “golden hour” and is critical, he said. “If you get patients to the right level of trauma care within that first hour, you have a much better chance of saving their lives and preserving their functions.”

Thompson anticipates more Mississippi hospitals coming back into the system, but he wouldn’t speculate on which ones they might be.

One Jackson hospital that hasn’t taken part in the past is now considering joining the trauma system.

“We haven’t come to a conclusion yet,” said Paul Arrington, vice president of St. Dominic Hospital. “We want to figure out what’s best.”

Two out-of-state hospitals expected to take part in Mississippi’s trauma system are the Med of Memphis and the University of South Alabama Medical Center in Mobile.

Depending on how many hospitals participate, the trauma fund could receive as much as $20 million annually from the hospitals that opt out. A combination of fees collected from driver’s license renewals, traffic fines, car tag collections, gun permit renewals, inspection stickers, boat registration renewals, motorcycle and ATV fees are expected to generate another $14 million annually toward trauma care. Those funds would then be used to compensate participating hospitals for treating uninsured trauma patients.

Connie Potter, executive director for the National Foundation for Trauma Care, called Mississippi’s new system “a fairly innovative solution” that’s easily the most ambitious among state plans.

Arizona is supposed to take in $20 million for trauma care through casino gaming. Tennessee is dedicating two cents of its cigarette tax to trauma care.

Nationwide, the foundation is pushing for $100 million in legislation before Congress to help cover the costs of uncompensated trauma care, Potter said. “There are too many people who are uninsured, too many people not covered by Medicaid.”

The challenge for Mississippi will be “attracting and retaining trauma specialists,” she said. “There is a dwindling supply of physicians.”

Then-Gov. Kirk Fordice signed the Mississippi Trauma Care Act in 1998, not long after suffering a near-fatal car wreck.

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www.aatn.us

Part of the approach the AATN uses to bring focus to health care providers is the fact that the Physicians, Nurses and equipment in the U.S. are the best and have no equal anywhere in the world.

However, when you have a system that still operates as it has since the 19th century, you already have a large hurdle facing the provider and more so the person seeking treatment.

Below is an article from Journal of the American Medical Association.

Dated July 21st, 2008

“At the heart of the challenge (health care reform) is transforming a 19th-century craft-oriented delivery system to provide 21st-century biomedical science and technology. Most physicians still practice alone, in partnerships, or in small groups. Small practices generally have less capacity to implement electronic medical records, less frequently use teams to care for patients with chronic illness, and are less able to provide statistically reliable and valid data on quality and efficiency measures. A more solid foundation of physician organizations is needed to avoid having the system crumble under the increased weight of greater demand for care and technological advances.”

www.aatn.us

MASSACHUSETTS’S UNIVERSAL health care law turned one in April. To survive, its guardians have had to make many changes, each of which has increased current and future government spending, increased the government’s role in regulating the healthcare market, decreased individual responsibility to purchase insurance, and made certain that the plan will fall far short of achieving universal coverage.

The promise of the law was simple and seductive: Require people to purchase health insurance, make the insurance affordable, or at least tax-deductible, and then fine those who don’t comply. Subsidies could come from the current money devoted to the Uncompensated Care Pool and the federal taxpayers. Universal coverage, then, would be achieved with little new spending.

Numerous problems existed with this plan, but the fairy tale quality appealed to politicians and the national media, so it passed to much fanfare.

Interestingly, the Commonwealth Health Insurance Connector Authority, the bureaucrats in charge of implementing the plan, decided that the universal individual mandate does not apply to everyone, but rather only those who can afford the premiums. Therefore, nearly one in five of the currently uninsured will be exempt from the law.

The Connector Board also bowed to pressure and reduced the monthly premiums on the subsidized-but-not-entirely-free healthcare plans. This will increase the program’s costs by $13 million.

Even at these reduced rates, the plans will still not be attractive to many. People earning between 151 percent and 300 percent of the federal poverty limit — $25,000 to $110,000 for families and $15,316 to $50,000 for individuals — are expected to pay up to 9.6 percent of their income on insurance premiums, or pay fines. (This 9.6 percent is before any co pays and cost sharing.) Meanwhile, taxpayers are still subsidizing them by as much as 94 percent of total costs.

The structure is a gourmet recipe for runaway spending. With this level of premium, those who don’t value insurance enough to make financial sacrifice to purchase it will neglect to do so. The fine — set at $216 — will be more attractive than the premium. Politicians will be under strong pressure to not enforce the mandate once the fines increase to meaningful levels. Indeed, they have already shown their willingness to back away from it for the 20 percent of people, and have set up a waiver process to exempt others on a case-by-case basis.

At the same time, the massive premium subsidy will make these plans extremely attractive to individuals who expect to use large quantities of healthcare. The population paying the premiums will be older and sicker than the general population. Spending will explode. It will come from somewhere, most likely the taxpayer.

Early data already provide evidence of this dynamic. As of April 1, 62,979 individuals had signed up for Commonwealth Care, the subsidized plans. Of these, 52,500 were enrolled in the totally free option. Give something for nothing, and people sign up. The plans in which people have to pay are a different story. Sign-ups have been slow, and the people who have enrolled are older and sicker than those signing up for the free plan.

The average age of a person in the free plan is 36, while the average age in the paid plans is 47. Of the free plans, there have been 214 specialty referrals per 1,000 enrollees. Of the paid plans, there have been 416 specialty referrals per 1,000 enrollees.

The system is set up to tax the young and healthy — who typically have both less income and less wealth — to subsidize those who are older and less healthy. One goal, according to the organization Health Care For All, is “to create a statewide credible risk pool, so healthy people ‘prepay’ toward their medical care.”

The problem with this is that the young and healthy, who are already prepaying for Medicare out of every paycheck, may object to this new form of taxation. According to the state’s own data, it’s not the young and healthy who use the Uncompensated Care Pool or who abuse emergency rooms, so the real point is the prepay or taxation and subsidization of a so-called risk pool.

So one year in, we have a plan that, even if no more concessions to liberal advocates are made, falls 20 percent short of its stated goal. Its costs have already increased by at least $13 million and are on track to skyrocket by some multiple of this once the doctors’ bills start coming in. Happy Birthday.

Sally C. Pipes is president and CEO of the Pacific Research Institute.

You want to know the scary part?  Compared to a year ago, new and start up businesses fell to less than half of the preceding year. Why?  New business owner, small and medium cannot afford the “New form of taxation without representation” Universal Healthcare is a economy killer and killer to your loved ones, because they have to wait one hundred thousand times longer to be seen, diagnosed and treated.

Take the example of a woman living in the UK whom waited over 6 months to find out why she was having excruciating and frequent headaches. In the U.S. as we are now, a simple scan would have revealed the treatable tumor growing in her head.  But alas, her family was lamenting her long wait when they laid her to rest because she could not make the appointment, which was  the day after her funeral.

Don’t believe half the things the news media says in regards to the U.S. Health care system being broken.  Its not, by the way compared to Canada, UK and Massachusetts, its by far better and you can bet your family on it.

Universal Health Care: Case closed

Prepared for the Commonwealth Fund Commission on a High Performance Health System, the National Scorecard on U.S. Health System Performance, 2008, updates the 2006 Scorecard, the first comprehensive means of measuring and monitoring health care outcomes, quality, access, efficiency, and equity in the United States. The 2008 Scorecard, which presents trends for each dimension of health system performance and for individual indicators, confirms that the U.S. health system continues to fall far short of what is attainable, especially given the resources invested. Across 37 core indicators of performance, the U.S. achieves an overall score of 65 out of a possible 100 when comparing national averages with U.S. and international performance benchmarks. Overall, performance did not improve from 2006 to 2008. Access to health care significantly declined, while health system efficiency remained low. Quality metrics that have been the focus of national campaigns or public reporting efforts did show gains.

Executive Summary

Every family wants the best care for an ill or injured family member. Most are grateful for the care and attention received. Yet, evidence in the National Scorecard on U.S. Health System Performance, 2008, shows that care typically falls far short of what is achievable. Quality of care is highly variable, and opportunities are routinely missed to prevent disease, disability, hospitalization, and mortality. Across 37 indicators of performance, the U.S. achieves an overall score of 65 out of a possible 100 when comparing national averages with benchmarks of best performance achieved internationally and within the United States.

Even more troubling, the U.S. health system is on the wrong track. Overall, performance has not improved since the first National Scorecard was issued in 2006. Of greatest concern, access to health care has significantly declined. As of 2007, more than 75 million adults—42 percent of all adults ages 19 to 64—were either uninsured during the year or underinsured, up from 35 percent in 2003. At the same time, the U.S. failed to keep pace with gains in health outcomes achieved by the leading countries. The U.S. now ranks last out of 19 countries on a measure of mortality amenable to medical care, falling from 15th as other countries raised the bar on performance. Up to 101,000 fewer people would die prematurely if the U.S. could achieve leading, benchmark country rates.

The exception to this overall trend occurred for quality metrics that have been the focus of national campaigns or public reporting. For example, a key patient safety measure—hospital standardized mortality ratios (HSMRs)—improved by 19 percent from 2000–2002 to 2004–2006. This sustained improvement followed widespread availability of risk-adjusted measures coupled with several high-profile local and national programs to improve hospital safety and reduce mortality. Hospitals are showing measurable improvement on basic treatment guidelines for which data are collected and reported nationally on federal Web sites. Rates of control of two common chronic conditions, diabetes and high blood pressure, have also improved significantly. These measures are publicly reported by health plans, and physician groups are increasingly rewarded for results in improving treatment of these conditions.

The U.S. spends twice per capita what other major industrialized countries spend on health care, and costs continue to rise faster than income. We are headed toward $1 of every $5 of national income going toward health care. We should expect a better return on this investment.

Performance on measures of health system efficiency remains especially low, with the U.S. scoring 53 out of 100 on measures gauging inappropriate, wasteful, or fragmented care; avoidable hospitalizations; variation in quality and costs; administrative costs; and use of information technology. Lowering insurance administrative costs alone could save up to $100 billion a year at the lowest country rates.

National leadership is urgently needed to yield greater value for the resources devoted to health care.

The National Scorecard

The National Scorecard includes 37 indicators in five dimensions of health system performance: healthy lives, quality, access, efficiency, and equity. U.S. average performance is compared with benchmarks drawn from the top 10 percent of U.S. states, regions, health plans, hospitals, or other providers or top-performing countries, with a maximum possible score of 100. If average U.S. performance came close to the top rates achieved at home or internationally, then average scores would approach 100.

In 2008, the U.S. as a whole scored only 65, compared with a score of 67 in 2006—well below the achievable benchmarks. Average scores on each of the five dimensions ranged from a low of 53 for efficiency to 72 for healthy lives.

On those indicators for which trend data exist, performance compared with benchmarks more often worsened than improved, primarily because of declines in national rates between the 2006 and 2008 Scorecards. Overall, national scores declined for 41 percent of indicators, while one-third (35%) improved, and the rest exhibited no change (or were not updated). Exhibit 2 lists indicators and summarizes scores and benchmark rates.

As observed in the first Scorecard, the bottom group of hospitals, health plans, or geographic regions is often well behind even average rates, with as much as a fivefold spread between top and bottom rates. On key indicators, a 50 percent improvement or more would be required to achieve benchmark levels.

Scorecard Highlights and Key Findings

The U.S. continues to perform far below what is achievable, with wide gaps between average and benchmark performance across dimensions. Despite some encouraging pockets of improvement, the country as a whole has failed to keep pace with levels of performance attained by leading nations, delivery systems, states, and regions. Following are major highlights from the Scorecard by performance dimension:

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Having worked in healthcare since the mid 1970s, there is no question that healthcare workers are dedicated to providing the very best care possible to each and every patient.  Now, given the public conversation about the extremely poor quality of healthcare, much supported by sound data, where is the missing link?

This missing link is not found in dedication, determination, or desire.  It is not found in facilities, equipment, medicines or resources. The missing link is found in the utilization of the resources and dedication of healthcare providers.

The quality of healthcare can be greatly improved with the use of process improvement tools.  These tools have been widely used in manufacturing and service industries.  The tools have also been used in healthcare and with significant results.  Reports of personnel efficiencies of over 25 % (reassign personnel to open positions, no one lost a job) attest to the assertion that there are many opportunities to improve.  When setup times are reduced by as much as 75%, more patients receive care and staff can go home on time. 

One of the process improvement tools is 5S.  It is an organization tool.  On the next shift, track the time you spent looking for ________ (fill in the blank with form, tape, report, bandage, etc).  Track the time you spent going to find ________ (fill in the blank with equipment, equipment that works, another type of equipment or supply, etc).  If your work area is like most, you will find that there are a number of items that you use regularly that are not in the most convenient place.  Do not feel alone with your results.  I experience the same when I go to my closet or my workshop.

The improvements that can result for a process improvement effort must endure.  Otherwise, our nature will move us back to the “old way”.  The implementation of a quality management system will help an organization to assure that the improved methods are maintained.  The system also helps the organization to develop a culture of continuous improvement.  One element of the quality management system that does this is internal audits.

Internal audits utilize in-house personnel to audit the work of another department.  The purpose of the audit is to assure that the steps of the process are being followed by everyone.  This will yield consistent results.  Now, if unacceptable results occur, the process is the focus of any post analysis.  Secondly, if a near-miss occurs, a process improvement team is formed to review the process and find ways to improve or error proof the process.  The person reporting the near-miss, is the most important member of the improvement team and is rewarded for identifying the possible process failure; not punished.

HealthQMS has a one-of-a-kind method of implementing quality improvement systems and process improvement tools to quickly produce results and maintain those improvements far into the future.

Terry McMillan