Researchers urge newly merged health systems to address patient risks, share data on quality and safety, and clearly define care oversight responsibility for the joint patient population.
Healthcare mergers and acquisitions could adversely effect patient safety as clinicians deal with changes in their practice setting, patient mix, and infrastructure, a JAMA study has found.
Researchers at Harvard University analyzed the patient safety risks for Harvard-affiliated institutions by speaking with clinicians and health system leaders. Their interviews uncovered three oft-unrecognized areas of "significant safety risks" that are linked to changes in patient populations, infrastructure, or clinician practice settings.
"Teams with little expertise in patient safety are typically responsible for implementing health care mergers, acquisitions, and affiliations," the study said. "Their primary impetus is often financial rather than clinical, and when the impetus is clinical, the concerns usually involve patient access and services rather than the way care is practiced in the affected institutions."
Because of that emphasis, the responsibilities for quality and safety are often unclear.
"As a result, risks to patients arise at the 'sharp end' of care, where clinicians are asked to practice in new settings, with new populations, or with new infrastructure, without sufficient planning," the study said.
New patient populations
After a merger, acquisition or expansion, health systems may experience changes in volume and demographics with patient populations.
While hospitals do a good job anticipating the needs of these new patient demographics or clinical services at the unit level, they may lag in ensuring that staff throughout the hospital are able to interact with these new patients.
"An increase in referrals may bring an influx of non–English-speaking patients, for instance, who require more interpreters, institutional relationships with different community services, and increased awareness of economic and social challenges these patients face in following care guidelines," the report said.
That lack of wider institutional attention to specialized needs can result in serious deficiencies in provision of safe, timely care, the report said.
Unfamiliar infrastructure
The researchers note that health system expansions and mergers often come with significant changes in supplies, equipment, formularies, protocols and electronic information systems, all of which can create a significant learning curve for clinicians.
"The attention clinicians must now give to once 'automatic' tasks also distracts from other aspects of patient care or slows throughput," the study said. "Unless schedules and capacity are adjusted, such shifts in time and focus not only may result in dissatisfied patients but also in increased likelihood of major errors."
New clinical settings for physicians
A survey of 82 healthcare institutions that have undergone expansions found that 87% require physicians, especially specialists, to travel to new practice sites.
"When clinicians travel, they often receive little systematic orientation to their new setting, leaving them to practice with infrastructure, processes, teams, and a clinical culture that can vary in significant and unexpected ways from those at their home institutions," the study said.
“In the absence of guidance, physicians indicated that they have adapted to these new circumstances through trial and error, which can put patients at risk."
The study offers some risk mitigation strategies, such as: providing "hands-on orientation" for new physicians about institution-specific emergency resources; and identifying all hospital units that may care for new patient populations but are not in the direct care path.
A federal judge says that Blue Cross Blue Shield's 'aggregation of competitive restraints' represent a per se violation of anti-trust laws. BCBS will appeal the ruling.
A federal judge in Alabama has ruled that agreements among Blue Cross Blue Shield companies across the nation to carve out markets and limit competition will be reviewed as inherent violations of the Sherman Anti-Trust Act.
U.S. District Judge David R. Proctor on Thursday ruledthat the "plaintiffs have presented evidence of an aggregation of competitive restraints…which, considered together, constitute a per se violationof the Sherman Act."
The granting of the plaintiffs' motion for partial summary judgment is the latest step in a five-year-long legal battle in federal court in Birmingham.
A Blue Cross Blue Shield Association attorney said the health insurer would appeal the ruling, which he called "one step in a lengthy process."
The plaintiffs, who include a class of BCBS customers, allege that the 36 Blue Cross Blue Shield companies have entered non-compete pacts that allocates the markets in which they sell health insurance and caps the amount of unbranded health insurance they offer.
The suit claims that the pact artificially inflates premiums and decreased consumer choice for health insurance.
"Our case alleges that, for decades, the Blue Cross Blue Shield system has operated as an illegal association of competitors trying to suppress competition in order to inflate their own profits at the expense of their customers," said Michael D. Hausfeld, lead counsel for the plaintiffs.
"We look forward to taking our case to trial and achieving a nationwide injunction to stop these practices once and for all," he said.
Scott Nehs, general counsel for the Blue Cross Blue Shield Association said he is confident that the insurers will win their appeal.
"The District Court stated that it is constrained by authority from the late 1960s and early 1970s, which we believe is inapplicable for a number of reasons," Nehs said. "The Blue Cross and Blue Shield System has served Americans well for almost a century, and we are disappointed by the court’s ruling with respect to certain aspects of the BCBS System."
Nehs said that the ongoing litigation will not affect operations for Blue Cross Blue Shield companies or their more than 106 million customers and healthcare providers.
"The BCBS System enables members to receive in-network medical care everywhere in the country and has substantial competitive benefits for consumers and medical professionals," he said
The American Hospital Association says the recommendation comes as hospitals are already grappling with record-low negative Medicare margins for services.
The Medicare Payment Advisory Commission (MedPAC) is calling for a big payment rate cut for some freestanding emergency departments.
The panel on Thursday unanimously recommended that "Congress should reduce Type A emergency department payment rates by 30% for off-campus stand-alone emergency departments that are within six miles of an on-campus hospital emergency department."
Like everything else with the nonpartisan MedPAC, recommendations are non-binding, and Congress is free to adopt the recommendations or ignore them.
The American Hospital Association (AHA) has come out as strongly opposed to the cuts in comments submitted to MedPAC. AHA said the recommendation "is not based on any analysis of Medicare beneficiaries, Medicare costs or Medicare payments and would make Medicare’s record underpayment of outpatient departments and hospitals even worse."
AHA said that Medicare margins were a record-low negative 14.8% for hospital outpatient departments and negative 9.6% for hospitals overall in 2016, with the latter expected to reach negative 11% this year.
At the same time, AHA said it supports a recommendation to allow isolated rural hospitals to convert to stand-alone EDs, and urged MedPAC to include EDs in vulnerable urban communities as well.
The action comes as hospital and Colorado public health officials continue their investigation of contaminated surgical equipment that could have exposed patients to HIV and hepatitis.
Acting on "an abundance of caution," Porter Adventist Hospital in Denver said Thursday it will temporarily suspend all surgeries at the hospital until it corrects water quality issues that could be linked to contaminated surgical equipment.
The suspension comes one day after the hospital sent notices to orthopedic surgery patients warning of a potential risk for infection from improperly cleaned surgical equipment. That breach is still under investigation, and it was not immediately clear if the contaminated water was the source of the breach.
"We made the decision to pause all surgeries after we noticed a potential change in our water quality relative to our surgical equipment," Porter Adventist said in a written statement.
"We are working closely with patients to reschedule surgeries, and we are supporting them through this process. We notified the Colorado Department of Public Health & Environment and they conducted a site visit on April 5."
On Wednesday, orthopedic and spine surgery patients treated at the hospital between July 21, 2016 to Feb. 20, 2018 were notified that they could have been exposed to surgical site infections for hepatitis B, hepatitis C or HIV.
It has not been made clear how many patients may have been exposed to potential infection, but Colorado public health officials said they are not aware of any patient infections related to the breach.
Porter Adventist said it is offering patients who underwent orthopedic or spine surgical procedures from February 21, 2018 to April 5, 2018 the opportunity to be tested for bloodborne pathogens.
"We will be notifying these patients directly via a written letter and will be providing additional information regarding surgical site infection," a statement from the hospital read. "As always, we are committed to patient safety and supporting them through this process."
"We recognize this news follows Wednesday’s announcement about a past gap in the pre-cleaning process of surgical instruments, prior to manual washing, machine washing, and sterilization," Porter Adventist said. "We continue to maintain that the risk of infection to patients is extremely low."
"We remain committed to maintaining the highest standards of patient care," the hospital statement read. "We understand that this information may cause concern, and are working closely with our patient care team, doctors and staff to ensure any patients involved have the information and resources they need."
The state health department was notified of the breach Feb. 21. The department conducted an on-site survey of infection control practices at the hospital. A disease control investigation is ongoing.
The department last visited the hospital March 28, confirming that current infection-control practices meet standards.
Porter Adventist stopped using and reprocessed all surgical equipment in question Feb. 20.
The suit alleges that CHS stonewalled an independent IT audit, which would show that the for-profit hospital chain was giving hospitals it had sold unlicensed access to software.
The troubles continue for Community Health Systems Inc.
Microsoft Corp. filed suit against the Franklin, Tennessee-based for-profit hospital chain this week, claiming that CHS has been "willfully infringing" on Microsoft's copyrights with extensive, unlicensed use of its software.
In the suit, Redmond, Washington-based Microsoft said it began investigating CHS' possible violations of its volume licensing agreement in 2016, when CHS began an extended string of hospital divestitures.
Since then, Microsoft said, its contractual right to an independent audit of the use of its software has been hobbled by CHS.
Under the contract, if an audit reveals 5% or more of CHS' use is unlicensed, the hospital chain has to reimburse Microsoft for the cost of the audit, and buy the licenses at 125% of the price for each product.
"CHS has been largely not responsive to, if not obstructionist of, Microsoft's contractual right to an independent verification," the Redmond, Washington-based software giant said in court documents.
Microsoft claims it has given CHS "every opportunity to comply with the independent verification process, and Microsoft has exhausted its best efforts to resolve this matter without judicial intervention."
"CHS' pattern of conduct, including missing numerous mutually agreed upon deadlines and providing incomplete data, demonstrates its unwillingness to comply with its contractual obligation and/or with the independent verification process," the complaint read.
In October 2016, Deloitte & Touche LLP was retained to audit CHS' usage of Microsoft software. Thus began a 16-month-long series of stonewalling tactics that included oft delayed or cancelled meetings, "ostensible technical issues," incomplete data submissions, and repeated missed deadlines, the suit alleges.
At one point, the suit alleges, CHS tried to include a non-disclosure agreement that would limit both the audit and the release of the information to Microsoft.
"Restricting the release of information to Microsoft would defeat the purpose of the independent verification process," the complaint read, "as it would prevent Microsoft from being able to fully verify CHS' licensing and contract compliance."
Finally, after months of badgering by Deloitte, CHS submitted data in December, 2017, that was still incomplete, but which showed that CHS' use of the software was more than 500% larger than what it had disclosed the previous January.
CHS did not return calls seeking comment.
The troubled company has been selling hospitals over the past two years in an effort to reduce a debt burden created with the ill-fated $7.6 billion acquisition of Naples, Florida-based Health Management Associates Inc. in 2013.
The Microsoft suit was filed in U.S. District Court in Murfreesboro, Tennessee. Read the complaint below:
Porter Adventist mailed letters to patients who had orthopedic or spine surgery, warning them of a potential infection risk owing to improperly cleaned surgical instruments.
Porter Adventist Hospital in Denver on Wednesday notified patients who had orthopedic or spine surgery within the past 20 months that they may have been exposed to surgical site infections for hepatitis B, hepatitis C or HIV.
"The process for cleaning surgical instruments following orthopedic and spine surgeries was found to be inadequate, which may have compromised the sterilization of the instruments," said Colorado Department of Public Health & Environment CMO Larry Wolk, MD.
The letters were sent to patients who had orthopedic or spine surgery at Porter between July 21, 2016 and Feb. 20, 2018, warning them of the potential infection risk.
It was not made clear how many people may have been exposed to the potential infections, but Colorado public health officials said they are not aware of any patient infections related to the breach.
Wolk cautioned that the risk of surgical site infection related to the breach is unknown, but that the risk of getting HIV, hepatitis B or hepatitis C because of this issue "is considered very low."
The state health department was notified of the breach Feb. 21. The department conducted an on-site survey of infection control practices at the hospital. A disease control investigation is ongoing.
The department last visited the hospital March 28, confirming that current infection-control practices meet standards.
Porter Adventist stopped using and reprocessed all surgical equipment in question Feb. 20. The hospital said there appears to be no increased risks to current surgery patients.
More Americans are accessing their personal electronic medical records, and find the data helpful and easy to use, but policymakers say half of the nation doesn’t see a need to do so.
The federal government today released a new online guide to help patients and their caregivers access personal electronic health records.
The guide, put out by the Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology, is designed to support the 21st Century Cures Act goal of improving patient access to electronic health information, and the MyHealthEData initiative , HHS said.
"It's important that patients and their caregivers have access to their own health information so they can make decisions about their care and treatments," said Don Rucker, MD, national coordinator for health information technology. "This guide will help answer some of the questions that patients may have when asking for their health information."
ONC said that in 2017, half of Americans reported they were offered access to an online medical record by a provider or insurer. This is up from 42% in 2014. More than half of people who were offered online access viewed their record with the past year. Eight in 10 people who viewed their information rated their online medical records as both easy to understand and useful for monitoring their health.
Despite those improvements, ONC said challenges remain. Almost half of Americans in 2017 who were offered access to an online medical record did not access their record, often citing a perceived lack of need as one of the reasons for not accessing their record.
ONC said the lack of use suggests that consumers are not aware of their HIPAA Privacy Rule right to access their health information, or the benefits that come with that access.
Study suggests that a variety of factors are at play when patients rate physicians, many of which are beyond the immediate control of the physician.
Negative online reviews of physicians on sites such as Healthgrades.com often are at odds with the more positive responses the same physicians get with patient satisfaction surveys, according to a new study this week in Mayo Clinic Proceedings.
Compared with colleagues without negative reviews, however, the physicians score lower on factors that go beyond patient interactions and are beyond their immediate control, the study found.
"Our study highlights the disconnection between industry-vetted patient satisfaction scores and online review comments," said study senior author Sandhya Pruthi, MD., an internal medicine physician at Mayo Clinic.
"Patients need to be aware of these distinctions as they make decisions about their health. Physicians also need to be aware, as they manage their online reputations," Pruthi said.
In a pilot between September and December 2014, researchers used Google searches and alerts to track negative online reviews of physicians at Mayo Clinic’s Rochester campus. Of 2,148 physicians, 113 had negative online reviews. The physicians represented 28 departments and divisions.
Researchers then compared these physicians’ scores in a formal patient satisfaction survey with the scores of other Mayo Clinic physicians in similar fields who had no negative online reviews. Researchers found no statistical differences in the overall scores, or in the scores for patient communication and interaction.
However, the group with negative reviews scored much lower on factors beyond patient-physician interactions, such as interaction with desk staff, nursing, physical environment, appointment access, waiting time, problem resolution, billing and parking.
Pruthi conceded that the study was limited because physician groups were small, as was the time period to collect data. The online reviews reflected single experiences of patients, and the data did not identify the instances or patient experiences that led to negative reviews.
In an editorial accompanying the study, Bradley Leibovich, MD, a urologist at Mayo Clinic, said the findings "underscore the totality and integrity of processes, elements and encounters – and not just the patient-provider interaction – that all need to be effectively and cohesively in place to ensure optimal patient experience and welfare."
The inconsistencies of physician reviews have been pointed out in other studies.
Hospital for Special Surgery researchers found discrepancies between doctor reviews provided by hospital websites and those posted on independent physician rating websites. Investigators found a much higher number of reviews and more favorable physician ratings overall on the hospital websites.
Federal prosecutors say the trio allegedly conspired to force Blue Cross and Blue Shield of Alabama cover diabetes services provided by Trina Health LLC.
An Alabama state legislator, a lobbyist, and a healthcare executive have been charged in a bribery scheme that attempted to coerce Blue Cross Blue Shield of Alabama into covering diabetes services provided by a California-based clinic, the Department of Justice said.
The Alabama defendants are State Rep. Jack D. Williams, 60, and Martin J. "Marty" Connors, 61, the former chairman of the Alabama Republican Party.
The California defendant is G. Ford Gilbert, 70, the owner of Carmichael, California-based Trina Health LLC, which operates diabetes clinics in 10 states and India.
According to the indictment, Trina Health opened three clinics in Alabama in 2014 and 2015, but was told that Blue Cross and Blue Shield of Alabama, the state's largest health insurer, would not cover the treatments.
Prosecutors allege that Gilbert schemed to force Blue Cross to change its position. He pushed a bill through the Alabama Legislature’s 2016 session that would require Blue Cross to cover the treatments and he allegedly bribed Alabama House Majority Leader Micky Hammon to make it happen.
Gilbert also hired Connors to lobby the bill. Conners worked with Hammon to recruit Williams, the chairman of the Alabama House's Commerce and Small Business Committee, to hold a public hearing on the bill.
The federal indictment charges all three defendants with conspiracy to commit bribery related to federal programs, conspiracy to commit honest services wire fraud, and honest services wire fraud.
The indictment also alleges that Gilbert and Connors committed bribery related to federal programs.
Gilbert is charged with wire fraud, healthcare fraud, and interstate travel in aid of racketeering.
The indictment does not include charges against Hammon because he is already in prison, having already been convicted in federal court of other offenses.
If convicted of the most serious offenses, Willams, Connors and Gilbert each faces a maximum sentence of 20 years in prison, fines, asset forfeiture, and restitution, DOJ said.
A strong majority of physicians responding to a one-question survey support work requirements for beneficiaries, despite opposition to the idea from the American Medical Association and other physician associations.
Three-in-four physicians favor a new federal policy that allows states to require Medicaid applicants to first prove they're working or looking for job, a new survey by Merritt Hawkins shows.
The single-question in the Dallas-based physician recruiter’s online survey asked 667 physicians what their position is on the new Medicaid work requirements policy. More than half (56%) said they feel very favorably about the policy, and 18% said they feel somewhat favorably.
Only 9% of physicians said they feel very unfavorably toward the policy and 8.4% said they feel somewhat unfavorably. The remaining 8% said they had no opinion either way.
"The survey strongly suggests that the majority of physicians would like to move away from the Medicaid status quo," said Travis Singleton, executive vice president of Merritt Hawkins.
"Many physicians have been frustrated for years because Medicaid often pays less than their costs of providing care," Singleton said. "Physicians have to limit the number of Medicaid patients they treat for that reason and want to focus on those who need care the most."
Kentucky, Indiana and Arkansas are implementing work requirements in their Medicaid programs. In Kentucky, able-bodied Medicaid applicants 19-64 years old will be required to put in 80 hours of community engagement a month to qualify for Medicaid benefits, which includes working, going to school, training for a job, or volunteering. The policies in Indiana and Arkansas have similar requirements.
"It remains to be seen whether the policy can be carried out fairly and effectively, but in concept, it appears to have the endorsement of most physicians," Singleton said.
The survey was conducted by email in early March and was completed by 667 physicians and has a margin of error of less than 1%, Merritt Hawkins said.
While the survey suggests overwhelming support for work requirements from physicians, elsewhere, the idea has proven to be controversial.
Delegates said the work requirements would increase administrative costs and impose documentation burdens on frail and vulnerable people.
In February, the American College of Physicians urged the Centers for Medicare & Medicaid Services to reject the proposals put forward by the three states.
"Our policy firmly states that being employed or conducting job search activities should not be a condition of eligibility for Medicaid," said ACP President Jack Ende, MD.
"Instead, Medicaid waivers should focus on providing greater access to health services and keeping patients healthy, rather than requiring them to work in order to receive care," he said.
