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Teaching Hospital Update September 12-16, 2011


 Email Alert
September 16, 2011
By Allison Cohen and Karl Thallner*

Big, Teaching Hospitals Missing From Joint Commission Top-Performers List

Although The Joint Commission's top-performers list honored 405 hospitals for successfully delivering evidence-based care, it also served as a warning to larger hospitals and academic medical centers, which noteably failed to make the list.

For example, some of the most renowned hospitals across the nation, including the Mayo Clinic, Cleveland Clinic, Geisinger Medical Center, Johns Hopkins University, New York Presbyterian Hospital, and Massachusetts General, were absent.

Why weren't these prominent hospitals on the list? Their 2010 compliance scores didn't hit the mark, according to The Joint Commission President Dr. Mark Chassin, who told reporters, "I would suggest asking the hospital that thinks [it] should have been on [the Joint Commission's] list why they think they're not on the list," notes HealthLeaders Media.

Instead, The Joint Commission's top performers included a large number of small and rural hospitals and twenty Veterans Affairs (VA) medical centers that each earned at least a 95% score for compliance with treatment standards, reports The New York Times.

Larger hospitals and teaching hospitals defended their delivery of care, noting they deal with higher volumes of--and often times sicker--patients. Such a busy environment can make it more difficult to achieve 100% compliance, notes The Times.

Nevertheless, Chassin said The Joint Commission's list should be "a wake-up call to larger hospitals to put more resources into these programs, and recognition that small, rural and community hospitals can do an excellent job."

The list also adds to the rising doubt surrounding "best hospital" rankings, as they are often misleading and incomplete. And not a single medical center listed in U.S. News & World Report's "Best Hospitals Honor Roll" was among The Joint Commission's 405 top performers, leading skeptics to question what factors should be included when rating hospitals.

Alicia Caramenico, Big, Teaching Hospitals Missing From Joint Commission Top-Performers List, Fierce Healthcare (Sept. 15, 2011).

"Poster Boys" Take a Pass on Pioneer ACO Program

During the healthcare debate, the Mayo Clinic, the Cleveland Clinic, Geisinger Health System, and Intermountain Healthcare were repeatedly touted as models for a new healthcare delivery system.

Now, they have something else in common: all four have declined to apply for the "Pioneer" program tailor-made by the Obama Administration to reward such organizations.

"When the poster boys ask that the posters be taken down, you have a problem," says Michael Millenson, president of Health Quality Advisors LLC. The lack of participation, he says, suggests that "somebody messed up": either the government didn't make the rules appealing enough, or "when push came to shove, the big players didn't want to play by the rules."

The four health systems are considered the most promising models for accountable care organizations (ACOs), a new approach to delivering healthcare services that rewards doctors and hospitals for providing high-quality care to Medicare beneficiaries while keeping costs down. The ACO provision became one of the most highly anticipated elements of the healthcare overhaul, and providers embarked on a frenzied race to join in as quickly as possible.

But when the proposed regulation for the program was announced in March, excitement fizzled.

Hospital and doctor groups complained that the program created more financial risks than rewards and imposed onerous reporting requirements. The American Medical Group Association, which represents nearly 400 large provider organizations, responded with a letter to the Centers for Medicare & Medicaid Services (CMS) warning that more than 90% of its members would not participate because of the reporting requirements and financial disincentives. In particular, the proposed rule would impose penalties for ACOs that do not achieve savings.

In response, the U.S Department of Health and Human Services (HHS) announced the Pioneer program in May, promising it would "provide a faster path for mature ACOs" like the Mayo Clinic that would allow the high-performing health systems to pocket more of the expected savings in exchange for taking on greater financial risk. HHS estimated that the Pioneer program could save Medicare as much as $430 million over three years.

CMS has been tight-lipped about how many health systems applied for the program and has declined repeated requests for the information by Kaiser Health News. The deadline to apply was August 19, 2011.

Jenny Gold, 'Poster Boys' Take A Pass on Pioneer ACO Program, Kaiser Health News (Sept. 14, 2011).

New Data Show Difficulties in Controlling Patient "Rebound" at Care Facilities

The Veterans Health Administration, the largest integrated healthcare system in the country, has long employed many of the approaches Medicare is pushing on all hospitals to reduce unnecessary readmissions. But new data show that VA hospital patients are just as likely to end up back in a hospital bed as are patients at private hospitals.

The new statistics underscore how hard it may be for hospitals to stop patients from rebounding back through their doors, a major goal of Medicare as it seeks to curtail the nation's ballooning healthcare costs.

VA hospital patients aged sixty-five or older suffering from heart failure, heart attacks, or pneumonia returned to a hospital within a month at the same rate as did Medicare patients initially cared for at private hospitals, according to an analysis of the data. The data were published by Medicare last month on its Hospital Compare website.

Out of 107 VA hospitals evaluated on the site, only one, based in Portland, OR, had significantly lower readmissions rates than did the average U.S. hospital, and that was only for one condition, heart failure. Fifteen VA hospitals had higher-than-average readmission rates for one or more of the three ailments tracked by Medicare.

"It makes you wonder how much hospitals can really control readmissions if a place like the VA cannot have dramatically lower rates," said Dr. Ashish Jha, a Harvard School of Public Health professor who also practices medicine at the VA Boston Healthcare System and advises the department's leadership.

"This is an organization that has been very focused on effective discharge planning," Jha said. "This is what the federal policymakers are trying to push the country towards. They're trying to create the kind of accountability the VA already has. On most other issues, the VA does very well, and yet on this one metric, not so much."

Dr. Peter Almenoff, a senior VA official, said the results "validate the fact that our care is as good as or better than in the private sector." He said that while the VA tracks readmissions to its own hospitals, it wasn't aware of the total picture, including readmissions to private hospitals, until Medicare published the data. "We're trying to understand why they come back, or go to local hospitals," said Almenoff, assistant deputy undersecretary for quality and safety at the VA.

By one estimate, readmissions cost Medicare $26 billion a year, with one in five patients landing back in the hospital within a month. Many experts say that while some of the returns are necessary, others could be avoided if hospitals made more of an effort to prepare and oversee patients after they leave.

But the current payment method used by Medicare and many private insurers can work against that, since hospitals are often eager to fill up their beds to earn more. "Currently, it's not always in the best interest of hospitals to do this work because they get paid for every admission," said Patricia Rutherford, a vice president at the nonprofit Institute of Healthcare Improvement in Cambridge, MA.

Jordan Rau, New Data Show Difficulties in Controlling Patient 'Rebound' at Care Facilities, Washington Post (Sept. 11, 2011).

Doctor Malpractice Data is Removed from Public Access by HHS

Patient advocacy groups are protesting the government's shutdown of public access to data on malpractice and disciplinary actions involving thousands of doctors nationwide.

The National Practitioner Data Bank maintains confidential records that state medical boards, hospitals, and insurance plans use in granting licenses or staff privileges to doctors.

Although records naming physicians aren't available to the public, the data bank for many years provided access to its reports with the names of doctors and hospitals and other identifying information removed.

That changed on September 1 when the data bank removed these public-use files from its website. The action came shortly after it learned that The Kansas City Star planned to use its reports.

The story, about doctors with long histories of alleged malpractice but who have not been disciplined by the Kansas or Missouri medical boards, was published on September 4.

The Star linked anonymous data bank reports to a Johnson County neurosurgeon by matching its information to the contents of court records of malpractice cases. Journalists often use this technique to glean additional information about doctors from the data.

"We've seen (The Star's) reporting and others that show your ability to triangulate on data bank data. We have a responsibility to make sure under federal law that it remains confidential," said Martin Kramer, spokesman for the U.S. Department of Health and Human Services' Health Resources and Services Administration, the agency that oversees the data bank.

Alan Bavley, Doctor Malpractice Data is Removed From Public Access by HHS, The Kansas City Star (Sept. 14, 2011).

Seniors Get More Medical Tests Than are Good for Them, Experts Say

Every year like clockwork, Anna Peterson has a mammogram. Peterson, who will turn eighty next year, undergoes screening colonoscopies at three- or five-year intervals as recommended by her doctor, although she has never had cancerous polyps that would warrant such frequent testing. Her eighty-three-year-old husband faithfully gets regular prostate-specific antigen (PSA) tests to check for prostate cancer.

"I just think it's a good idea," says Peterson, who considers the frequent tests essential to maintaining the couple's mostly good health. The Fairfax County resident brushes aside concerns about the downside of their screenings, which exceed what many experts recommend. "Most older people do what their doctors tell them. People our age tend to be fairly unquestioning."

But increasingly, questions are being raised about the overtesting of older patients, part of a growing skepticism about the widespread practice of routine screening for cancer and other ailments of people in their seventies, eighties, and even nineties. Critics say that there is little evidence of benefit--and considerable risk--from common tests for colon, breast, and prostate cancer, particularly for those with serious problems such as heart disease or dementia that are more likely to kill them.

Too often these tests, some doctors and researchers say, trigger a cascade of expensive, anxiety-producing diagnostic procedures and invasive treatments for slow-growing diseases that may never cause problems, leaving patients worse off than if they had never been tested. In other cases, they say, treatment, rather than extending or improving life, actually reduces its quality in the final months.

"An ounce of prevention can be a ton of trouble," observed geriatrician Robert Jayes, an associate professor of medicine at George Washington University School of Medicine. "Screening can label someone with a disease they were blissfully unaware of." Dartmouth physician Lisa Schwartz cites one such case: a healthy seventy-eight-year-old man who was left incontinent and impotent by radiation treatments for prostate cancer, a disease that typically grows so slowly that many men die wit--but not of--it.

The U.S. Preventive Services Task Force, an independent panel of experts that evaluates the risks and benefits of screening tests, does not endorse PSA testing or routine colon screening after age seventy-five. The panel, whose recommendations will guide some coverage decisions under the 2010 federal health law that expands access to screening, says there is no evidence for or against mammography after age seventy-four and recommends that most women stop getting Pap smears to detect cervical cancer after age sixty-five.

So far the task force's guidelines appear to have had limited impact. Researchers in June reported in the journal Cancer that nearly half of primary-care doctors would advise a woman with terminal lung cancer to get a routine mammogra--even if she was eighty years old. A 2010 JAMA study of more than 87,000 Medicare patients found that a "sizeable proportion" with advanced cancers continued to be screened for other malignancies. Last May, Texas researchers reported in the Archives of Internal Medicine that 46% of 24,000 Medicare recipients with a previous normal test underwent a repeat colonoscopy in less than seven years and sometimes as few as thre--compared with the ten years recommended by the task force. In nearly a quarter of cases, the repeat test was performed for no discernible reason. (Medicare is supposed to cover the screening test, which can cost about $2,000, only once a decade if no cancer or polyps have been found, but the program paid for all but 2% of the procedures reviewed by the Texas researchers.)

"More is not always better, and that becomes particularly true in older Americans where the dangers of medical care grow," said Michael LeFevre, a professor of family medicine at the University of Missouri School of Medicine who is co-vice chair of the task force. "The older you get, the more likely it is that something else is going to make you sick or die." Colon polyps take ten to twenty years to become cancerous, while the risks from colonoscopy, including intestinal perforation and heart attack, substantially increase after age eighty.

Experts point to several reasons for the persistence of overscreening: habit; incentives that pay doctors and hospitals for individual procedures; quality assessments that rely on how many patients receive such tests; physicians' fears of missing something important or of upsetting elderly patient--or their children--by suggesting that screening is unnecessary because a patient is too old or too sick to benefit.

In an era where discussions about end-of-life care are branded as "death panels" and curtailing unnecessary and expensive testing is regarded by some as rationing, experts say it is not surprising that overtesting endures. Many doctors say that it's easier to simply order a test than to discuss its risks and benefits with patients.

But some doctors believe it's time to resist. "I think we need to say we can't do everything for everybody, and it doesn't make sense," said Washington radiologist Mark Klein, who recently performed a virtual colonoscopy on a ninety-nine-year-old woman. Klein said he considered not doing the procedure but decided to go ahead because he didn't learn how old the patient was until she was lying on the table, having undergone the prep.

"The most important thing on any referral is the date of birth," said Klein, who said he tries to talk some older patients and their doctors out of pursuing tests and treatments he considers overly aggressive. "The game is not finding things, it's can you improve mortality? And if you do find something, it's very hard for a doctor to say, 'don't do anything'?"

Sandra G. Boodman, Seniors Get More Medical Tests Than are Good for Them, Experts Say, Washington Post (Sept. 12, 2011).

State Challenging Hospitals' Tax Exemptions

Facing a budget deficit exceeding $11 billion, the State of Illinois in recent weeks has begun challenging the property tax exemptions of some of its best-known hospitals, saying they should pay more because they are not providing enough charity care.

The Illinois Department of Revenue moved last month to strip property tax exemptions from Prentice Women's Hospital, a sparkling new medical center in Chicago's tony Streeterville neighborhood; Edward Hospital, a rapidly expanding medical center in the western suburb of Naperville; and Decatur Memorial Hospital in central Illinois.

If successful with those three, the state is expected to look for other nonprofit hospitals with low percentages of charity care, with an eye toward challenging their property tax exemptions, too. A Department of Revenue spokesman said that the agency was reviewing parcels owned by fifteen hospital systems, but declined to say if the tax exemptions would be challenged in each case.

All three of the hospitals the state is focusing on provided free and discounted medical care that ranged from 0.96% to 1.85% of patient care revenue, according to the revenue department. The state also said that each one had been operating as a "for profit" business when the state's Constitution says that "only charities are entitled to a tax exemption."

In anticipation of new tax challenges, hospitals in Illinois are preparing a lobbying push that would seek to redefine the qualifications for tax exemptions. The new definition would go beyond just charity care and expand to include patients' unpaid debts, costs of medical care not covered by Medicare health insurance for the elderly, Medicaid coverage for the poor, as well as direct costs that teaching hospitals pay to train doctors and conduct research.

In interviews, executives of the Illinois Hospital Association told the Chicago News Cooperative that they had discussed with state policy makers a plan to draft a broader legal definition for hospital tax exemptions. The lobbying group--which is adding staff members to bolster its effor--would also figure into a hospital's tax exemption the cost of subsidizing money-losing services like emergency care, trauma care, burn units, and neonatal intensive care units.

Bruce Japsen, State Challenging Hospitals' Tax Exemptions, New York Times (Sept. 10, 2011).

AHLA Teaching Hospital Updates are intended to provide quick summaries of cutting-edge issues of interest to teaching hospitals and their counsel. Additional information and more in-depth coverage on these topics may be available from AHLA Health Lawyers Weekly and appropriate AHLA Practice Groups.

*We would like to thank Allison Cohen, Esquire (Washington, DC), and Karl Thallner, Esquire (Reed Smith LLP, Philadelphia, PA), for providing this week's update.

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