BLOG Medicine

All That and a Bag of Chips

Walk-in clinics in retail outlets and drugstores like CVS, Duane Reade, and Wal-Mart continue to grow in prevalence, with people flocking to them because they tend to be cost-effective, convenient, no appointment necessary, and many have wait times of less than 15 minutes.

Retailers got more aggressive about staking their claim in the fast-growing business last July when CVS Corp., the largest drugstore chain in the country, acquired Minneapolis-based MinuteClinic, the pioneer and largest provider of such retail-based health clinics in the U.S.  MinuteClinic had already grown from 19 clinics in 2 states to 83 clinics in 10 states in just one year.  With 175 clinics in 20 states, CVS broke new ground last week in Chicago, opening 5 clinics, the first of their kind in the area, with plans for 30 more in the next year.  CVS has also asked Massachusetts health officials for approval to open the first of 20 to 30 planned MinuteClinics in Boston-area stores.  CVS is in negotiations with Blue Cross and Blue Shield of Massachusetts, Harvard Pilgrim Health Care, and Tufts Health Plan to cover their members' visits.

Other retailers are also expanding.  Wal-Mart had plans to expand their 12 existing clinics to include another 50 by end-of-year 2006.  Wal-Mart has allowed several companies to run their clinics.  One of them is RediClinic, run by InterFit, a private company backed by AOL founder Steve Case.  InterFit has plans to add another 500 clinics by 2009.  The other big competitor is Take Care, which runs 16 clinics in Rite Aid, Osco, and Walgreens and has plans to open 1,400 clinics by the end of 2008.

The clinics are typically staffed by certified nurse practitioners and physician assistants and can offer treatments at a fraction of the cost for the same treatment provided in the average visit to a doctor or at the emergency room.  Patients are understandably enthusiastic.

Physicians, however, aren't embracing the retail clinics.  In June 2006, the American Academy of Family Physicians, stated that they don't endorse any particular retail health-clinic business model or company, reiterating that the clinics can only complement the work of family doctors and other primary-care physicians.  The organization also recommended that its member physicians adopt a system of "open access" scheduling and provide same-day appointments to keep patients happier and healthier and state medical societies are pushing legislation that would regulate retail clinic operations and marketing.

In Massachusetts, although there has been no organized opposition, yet, health officials are moving cautiously.  Concerns range from a CVS request to waive some medical clinic certification requirements, to disrupting existing patient and referral relationships, to the potential financial strain that may arise if the MinuteClinics siphon off the easier cases to leave only the more complex, and more expensive cases, to existing physician practices.■

Divided We Fail

AARP, Business Roundtable and SEIU have launched a campaign to focus the 2008 election on health care and financial security issues in states with early presidential primaries and caucuses.

The joint effort, titled "Divided We Fail," is based on the platform that all Americans should have access to affordable, quality health care and peace of mind about their future long-term financial security.■

New Orleans Health Care System's Slow Road to Recovery

This week, two separate media outlets followed up on the story of the New Orleans Health System's slow recovery.

PBS Online NewsHour provides a transcript of the two-part Jim Lehrer NewsHour interview with local healthcare authorities, while NBC's Nightly News reported on the hospitals and health clinics struggling to meet the demand for medical care more than a year and a half after Hurrican Katrina.

Nineteen months after the hurricane, 6 of 11 hospitals remain closed and fewer than one-third of the healthcare professionals have returned to the area.  Patients can wait up to 8 hours to see a physician and up to two days for a hospital bed.

Louisiana is set to receive a $15 million federal grant to provide up to $110,000 in incentive payments to primary care physicians and other health care professionals to move to New Orleans or surrounding areas.

HHS Secretary Mike Leavitt has said that no additional federal funding will be made available, but state and federal authorities are exploring alternative arrangements for caring for the uninsured.  According to a Department of Health and Human Services report conducted by LSU's Public Policy Lab, the total number of uninsured residents in the state as of fall 2006 was 657,027.  Of those without insurance, 446,645 earned below 200 percent of the Federal Poverty Level.■

A Business of Caring

Early in my career, I had the opportunity to participate in a "guest relations" program at an academic medical center in Cleveland.  As a newly-minted physician relations manager, I knew I could only grow, professionally, from the experience and readily volunteered.

The program paired non-clinical hospital management with the family members of patients who were long-stay or terminally ill.  The idea was to provide a brief respite from the obvious stress involved with such situations, and, as non-clinicians uninvolved with direct patient care, we would be seen as non-adversarial to the patient's family.  We were to have dinner, at the hospital's expense, in the senior staff dining room which came with an elegant setting and an equally high-caliber chef.  Conversation was to be directed by the patient's family and specific talk about the patient and their stay was discouraged, but not forbidden.

I ended up paired with two mothers, each with their own child (one a tween, the other a teen) in the cystic fibrosis unit.  If you are unfamiliar, cystic fibrosis is an inherited chronic disease that causes the body to produce unusually thick, sticky mucus that affects the lungs and digestive system.  At the time, the predicted median age of survival was significantly less than today's 37 years and with some 70% of cases diagnosed by age two, these mothers had already lived with their children's disease, and the consequent and frequent inpatient stays, near to its expected term.

After a brief introduction and assurance that this fresh-faced young man was indeed the hospital manager they were meant to meet, we sat down to dinner.  What followed was one of the most exceptional and fulfilling experiences of my professional career in healthcare.

Initial talk had been about why their children were inpatients at the hospital, the facts about the disease, the length of the current stay, and what number visit this stay made for the year, so far -- a matter-of-fact, dry monologue that was far from hopeful, let alone a distracting respite for these weary women.

At this time, I had been at the hospital just over a year-and-a-half, having recently finished setting up the physician referral program for the health system.  In order to manage my newly hired staff of 15, I had to know about, and had entered into our database, every piece of available information about every program, service, attending, and admitting physician affiliated with what is the largest academic medical center in Northeast Ohio.  The project had taken over 16-months to complete and, at the end, I could and did write entire sections of the physician directory from memory -- if the service was provided by our hospital, I could tell you at which building, on what floor and who headed up the program.  I could talk the talk; however, I hadn't walked the walk.

Already in a negative frame of mind, when the mothers found out that I had never actually been to the cystic fibrosis unit, I prepared myself for disapproval and recrimination.  Instead, their focus immediately shifted from reliving their children's illness and pain to one of superiorly-informed docent.

For the next several hours, they took me, floor-by-floor, through the children's hospital, showing me where the patient's of the programs I had written about, and facilitated referrals to, experienced their care (some of the best in the nation, some would say world).  They had walked these halls numerous times over the years, and various inpatient-stays of their children, and would introduce to me, by name, almost every charge nurse.  They put a face to each service, patient, and family; they made real what had only been academic.

And, during this, they weren't thinking about the suffering of their own children, or how long this stay would be, or how much longer they may have with their child before finally losing them to their disease.  They allowed themselves, instead, to be distracted for a short while; to re-energize themselves, ironically enough, through the process of better informing me why they brought their children to this place for care; proud to educate me about the hospital I thought I already knew, making me understand why they entrusted us with the care and comfort of their sick and dying.

I walked away, that night, having accomplished the goal of the program, yet having received much more than I had given.  Every service now came with a face; I saw who we treated and where.  What had been a business of information had become a business of caring.

In the end, although not exactly as expected, I understood that I had been right; I had grown from the experience.■

2007 Hospital Pulse Report

If you want to be happy with your inpatient hospital stay, move to Oklahoma City, according to Press Ganey,  the Indiana-based patient satisfaction measurement company; and, if wind-swept plains aren't your cup of tea, Milwaukee, New Orleans, Indianapolis, Columbus, Sacramento, Kansas City, Nashville, Miami, and Boston make up the remainder of the top ten metropolitan areas with the higest inpatient satisfaction.

The company recently released the 2007 Hospital Pulse Report: Patient Perspectives on American Health Care that examines the experiences of more than 2.3 million patients treated at more than 1,700 acute care hospitals throughout the nation.

Key findings include:

• Overall patient satisfaction increased, but there continues to be variation by metropolitan area, hospital size, patient age, and other demographics
• Obstetrics and gynecology patients report the highest patient satisfaction compared to all other patient care specialties
• Patients are three times more likely to write a positive comment about their nurse or physician than a negative comment
• Patients are far more critical of their physical surroundings than of their care
• The top priority, from the patient perspective, for improving inpatient experience is the hospitals ability to respond to patient concerns and complaints
• A hospital's ability to provide attention to the patient's needs is the strongest predictor of a facility's overall performance score on HCAHPS public reporting tool
• To enhance patient perceptions of safety, hospital staff must provide information to aid in a patient's decision making

Consistent with previous reports, frontline staff continues to have the greatest impact on the patient's overall experience.■

Online Survey of Health Leaders Favorable Toward SCHIP

An online survey conducted by Harris Interactive of a panel of opinion leaders in health policy and innovators in healthcare delivery and finance finds that large majorities feel the State Children's Health Insurance Program (SCHIP) has been successful in increasing access to health care for low-income children (71%) and in reducing the rate of uninsured, low-income children (65%).

Survey Highlights include:

• 71% felt SCHIP has been successful in increasing access to health care for low-income children and 65% said it was successful in reducing the rate of uninsured, low-income children
• A majority (56%) say SCHIP has been extremely successful or successful in improving preventive care and quality of services for children
• 88% favor (strongly favor or favor) allowing states to cover children up to 300% of poverty
• 91% were in favor of making SCHIP available to legal immigrant children
• 73% say after covering children, states should be allowed to cover childless adults under 100% of poverty
• 80% were in favor of extending SCHIP coverage to parents of children in SCHIP in the absence of comprehensive action on the uninsured
• 80% favor requiring states to adopt best practices for outreach and enrollment
• 84% favor allowing states to design packages that wrap around other coverage (e.g., translation services and care coordination)
• 78% favor requiring states to reward managed care plans/providers that meet benchmark levels of performance on developmental screening, preventive care, and follow-up treatment
• The Bush Administration's proposal to limit SCHIP coverage to children under 200 percent of the federal poverty level was not favorably received, with only 14 percent supporting such a limitation

The online survey was delivered by e-mail to a panel of 1,467 developed by The Commonwealth Fund, Modern Healthcare, and Harris Interactive; 170 responded.  Data from the survey wasn't weighted, is not based on a probability sample and, therefore, no statistical sampling error can be calculated.■

Massachusetts Health Reform

The Boston Globe recently reported that Massachusetts has made great strides toward ensuring that all state residents have health insurance, but still faces significant obstacles.

While more than 110,000 people -- approximtely one-quarter of the state's uninsured -- have been given free or heavily subsidized coverage in the past year, and the use of state money to pay for charity care at hospitals has begun to decline, the big tests of the universal health insurance law are yet to come.

Compromise was reached this year on issues of how much people can be expected to pay for insurance, what constitutes real insurance, and who will be exempted from the requirement that everyone have coverage by 1 July, which helped retain support from the alliance of businesses, medical providers, and advocates that formed to get the law passed.

It remains to be seen, however, if low-income people who have to pay for even substantially subsidized insurance will sign up.  Most of current enrollees in partially subsidized programs are older and sicker necessitating that younger, healther people enroll lest costs rise too rapidly and plans become unaffordable to everyone.  Compounding the problem is public confusion about the many subsidized and unsubsidized insurance plans now being offered.  Aggressive recruitment and education advertising has begun with a broader campaign targeted at uninsured middle- and upper-income individuals set to begin in May.

Not surprisingly, the biggest challenge is financing.  Federal funds (totalling nearly $400 million) that are committed through 30 June 2008 and the state's free-care pool, now pay for charity care at hospitals and health centers.  The state must renegotiate an agreement with the Bush administration to guarantee continuation of the federal funds and additional federal funds, to cover children, are dependent on Congress overriding President Bush's objections to a broad expansion of SCHIP.  The state can shift the $605 million from the free-care pool only if the many people currently seeking charity care get insurance coverage.

Rising healthcare costs also threaten the insurance initiative, whose cost is estimated at about $1.6 billion for 2007.  With no cost controls in the state that has the most expensive healthcare in the world, premiums are continuing to rise rapidly and revenues are becoming inadequate to cover the costs.■

APHA Renews Call for Expanding Health Coverage for Children

On 23 April 2007, the American Public Health Association (APHA) renewed its call for expanding health care coverage for children through Medicaid and the State Children's Health Insurance Program (SCHIP).

In APHA's brief, "Reauthorization of the State Children's Health Insurance Program: A Key Step to Covering all Kids," APHA urges Congress to:

• ensure that a minimum of $60 billion in additional funds is provided over five years for children's health coverage
• assure that states have ample dollar to cover most children eligible for Medicaid or SCHIP, and give states financial incentives for covering more uninsured kids in their Medicaid and SCHIP programs
• strengthen the federal standard for SCHIP benefits packages to make it comparable to the Medicaid benefits package, which includes coverage of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services
• provide adequate funding and give states the option to cover pregnant women and legal immigrant pregnant women and children in their SCHIP programs
• make revisions to federal law to give states the flexibility to deem children eligible for and enroll them in SCHIP or Medicaid based on information from other means-tested programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the National School Lunch Program
• allow states the flexibility to determine the citizenship status of SCHIP and Medicaid applicants

APHA also maintains SCHIP Resources and News on their State Children's Health Insurance Program page.■

Tennessee Hospitals Inform

The Tennessee Hospital Association went public 23 April 2007 with a web site telling patients, in advance, how much they'll pay.

The site, Tennessee Hospitals Inform, lists the median charges billed for the most common diagnosis-related groups at most of the state's 136 hospitals, using prices from hospital's most recent annual reports to the state.  HCA-owned hospitals prices aren't listed, but there are links to the company's own cost-of-care site.

The site also includes a link to the HospitalCompare, the US Departement of Health and Human Services site that maintains quality information backed by top health care experts and federal government agencies.■

AHIP Advances National Strategy to Improve Health Care Safety and Quality

America's Health Insurance Plans (AHIP) study, "Raising a Higher Bar," released 20 April 2007, calls for the creation of a new entity to compare the safety and efficacy of medical procedures and technologies, advocates steps to promote healthcare transparency and speed the adoption of best practices, and calls for the creation of a new patient-centered dispute resolution mechanism.

The AHIP plan advocates a 3-point program: creating a new public-private partnership charged with providing up-to-date and objective information on which health care services are most effective and provide the best value; assuring FDA authority to monitor long-term impact of new drugs, devices, and biologicals; and, adopting a national medical research agenda that closes gaps in knowledge and provides actionable information to patients and physicians.

The new plan to improve quality and safety follows a proposal to expand access to coverage released by AHIP in November 2006.  Because of the clear similarities to HHS Secretary Michael Leavitt's Value Exchange plan, unveiled late February 2007, it's unclear if the AHIP plan is a counter to the HHS plan, is meant to complement the HHS plan, or run parallel to the federal program.  It's also unclear how a new patient-centered dispute resolution mechanism is different than, or improves upon, the dispute resolution process advocated by the American Medical Association (AMA) in their "Model Managed Care Agreement," 4th edition, 2005.

What is clear is that healthcare reform remains a priority for everyone involved, but divergent agendas don't build consensus, and plans that purport to be new and visionary, but aren't, can only fail.■