Recently, MSNBC reported that a Rhode Island doctor is facing a $500 fine and must take a continuing education course after inadvertently revealing a patient's identity during a Facebook post meant to outline some of her clinical experiences. According to the article, the doctor did not directly identify the patient, but described his or her injuries in a fashion that allowed a third party to figure out the patient's identity.

In some ways, this is the perfect cautionary tale for hospitals and docs who, like everyone else, now reach their customers via tweets and status updates. Unlike some HIPAA breaches I've heard about—stories of medical students posting patient photos on Facebook abound—the doctor in question appears to have had no intent of making light of her patient's condition or exposing their identity. And my assumption is that the lightness of the penalty, doled out by Rhode Island's medical licensing board, reflects that lack of intent—although at least one of the hospitals where she has clinical privileges terminated those privileges following the incident.

But it does raise some concerns as hospitals and doctors increasingly market themselves on Twitter, Facebook and other social media vehicles, instead of through more traditional media and community relations outlets. Hospitals don't have much choice in the matter—every business is migrating from face-to-face interactions and exposure through newspapers and TV to real-time social media encounters with the general public, but I think some caution about the extent of exposure, and social media guidelines for staff, are imperative, especially as more hospitals use clinical encounters as a chance to promote their services via Twitter and live webcasts.

My sense is that we're still in a period of unsettled chaos with Twitter, Facebook and other social media forms, and that eventually, informal and legal boundaries will begin to self-police what is still a young form of communication. Until then, tweet with caution.

Can HIPAA and other privacy protections remain meaningful—and enforceable—in an era where every action is tweeted and where we're all encouraged to share every detail of our professional and private lives? And does your hospital have a Facebook or Twitter policy to handle the pitfalls of social media? E-mail your thoughts to hbush@healthforum.com.

You could get very dizzy watching all those revolving doors—the ones spinning people in and out of hospital executive suites these days.

Though the turnover rate of hospital CEOs dropped slightly in 2010—to 16 percent, from a 10-year high of 18 percent in 2009, according to the American College of Healthcare Executives—that's still a hectic pace, and it's bound to pick up as baby boomers stampede into retirement. Some 60 percent of hospital CEOs are over 55 and by some estimates, a jaw-dropping 75 percent of health care organization CEOs will retire in the next 10 years.

And don't expect the doors to suddenly stop revolving once the boomers are gone. Those Gen Xers now eyeing the corner office over the tops of their Facebook pages "do not seek jobs for life or the gold-watch or silver-tray trappings of longevity," warns a white paper from executive services firm B.E. Smith. As for Generation Y? They "tend to think that a good job lasts three to five years."

In other words, the days of the CEO-for-life are vanishing, if they really ever existed. Back in 2006, an ACHE survey found that only a tiny fraction—3.4 percent—had served at the same institution as CEO for more than 20 years. The median tenure of a hospital CEO was just 43 months.

If, as expected, that "churn" intensifies, it will be very hard on hospitals. "The loss of a CEO can cost a health care organization $1.5 million in severance, recruitment expenses and the new CEO's salary," write B.E. Smith's Zachary N. Beesher and Christine Ricci. Moreover, it often prompts others on the executive team to leave, and it delays construction projects, new equipment purchases, physician recruitment programs and new service development.

That's not all: If there's a whiff of instability at the top, staff morale and public perception suffer, and competitors might take advantage of the situation by trying to poach members of the medical staff.

All of which ought to be motivation enough for CEOs and board members now in place to keep a sharp eye out for young staffers or job candidates with leadership potential. They should also get very familiar with what those up-and-comers expect in their careers. The expectations are, to put it mildly, "nontraditional," a fact that might stick in some boomers' craws. But it's essential for the long-term viability of an organization to understand them, adapt accordingly and build a reputation as an attractive place for Gen Xers and Yers to work.

Here are some characteristics of younger professionals identified in the B.E. Smith report:

• Because they don't plan to stay with one organization forever, they "prefer benefits loaded on the front end or a flat salary out of which they can fund their own benefits."
• They respond well to 15-25 percent management or productivity incentives and bonuses.
• They will not work the long hours their predecessors put in, and they want flexible schedules to allow a balanced work-home life.
• They need "constant feedback on performance and one-on-one time with supervisors."
• They "relish prompt recognition, even if it involves a simple card, thank you or token of appreciation."
• They "quickly grasp new concepts and are avid users of technology."
• Coaching is advisable, preferably "a formalized process that uses professional coaches to achieve specific, measurable outcomes, holds both coach and student accountable and focuses not only on organizational goals, but also on personal development."

By the way, several recent surveys have found that far too few CEOs are paying any attention at all to leadership succession plans. That can't be good.

How is your hospital preparing for the next generation of leadership? Or is it? Let me know at bsantamour@healthforum.com. And look for my column every Tuesday in this space.

In the month since the 429-page proposed rule for Medicare's Accountable Care Organization program has gone public, and with a little more than 8 months remaining until the program starts in earnest in 2012, concerns from observers and interested parties have unsurprisingly piled up, a natural response to a major initiative hailed by its supporters as one of the keys to reducing long-term health care costs at the same time it improves overall health care outcomes.

The newest addition to the chorus of skeptics entered my inbox Friday—a new study out from the George Washington University School of Public Health warns that ACOs may not fully serve Medicare beneficiaries in underserved communities. The report points out that federally qualified health care centers, which currently serve 1.4 million Medicare beneficiaries among their 19 million low-income patients, are not allowed to form ACOs. In addition, the report argues that ACOs will be discouraged from even including health centers in their organization, "because of its prohibition of the assignment of FQHC Medicare patients to ACOs for shared savings purposes." 

The report notes some incentives designed to bolster FQHC participation in ACOs—including an increase in shared savings if an ACO includes an FQHC, and an exemption from some of the requirements related to shared savings thresholds if patients have at least one encounter with a health center. But it concludes that the impact of the rule will "exclude the poorest beneficiaries with the highest health risks," and will discourage hospitals from affiliating more closely with health centers.

Of course, this is the stage in any regulatory process—as CMS solicits feedback to the proposed rule before it finalizes it—when concerns by interested parties are meant to be raised, and hopefully addressed by CMS in some form or another. Texas-based VHA, a network of not-for profit health care providers, for instance, argued in a recent New England Journal of Medicine article that participating providers in ACOs may be underwhelmed by immediate financial results. The American Medical Association, meanwhile, is worried that not all physicians who want to join an ACO will be able to participate.

It's also a good time for would-be ACO players to get up to speed on what those 429 pages will mean for their particular institution, and tomorrow, the American Hospital Association is hosting a members-only town hall where hospitals can can hear from federal regulators and AHA experts on barriers to ACO participation and possible remedies—click here for more information.

In the meantime, I'd like to hear from you, the reader. Email your issue, concern or, pray tell, your unabashed enthusiasm for the proposed ACO rule to hbush@healthforum.com, and I'll feature some of the responses in an upcoming column, along with other feedback I've recently received on ACOs.

A new report from the Dartmouth Atlas finds that chronically ill Medicare patients are logging fewer hospital days and receiving more hospice care in the last six months of life, leading to a decline in the percentage of chronically ill patients who died in a hospital from 32.2 percent in 2003 to 28.1 percent in 2007. The report also found that chronically ill Medicare patients who are admitted to hospitals are spending more time in intensive care and receiving more visits from physicians.

Among the other key findings:

• The average patient logged 10.9 hospital days in the last six months of life in 2007, down from 11.3 days in 2003.


• 36.1 percent of chronically ill patients were treated by 10 or more doctors in 2007, up from 30.8 percent in 2003.


• Among 35 academic medical centers surveyed, 22 reported increases in the number of patients seeing 10 or more doctors in the last six months of life from 2003-2007.


• In 2007, chronically ill patients in Manhattan averaged 20.6 days in the hospital in their last six months of life, nearly four times higher than in Ogden, Utah, where those patients averaged 5.2 hospital days.

Read the full report here.

Tucked away in the Affordable Care Act is a provision that may give some rural hospitals a little bit of—and much needed—financial breathing room. The law expands the Rural Community Hospital Demonstration Project, which tests what happens when so-called tweener hospitals are paid on cost-based reimbursement. Tweeners are too big to be a critical access hospital, and thus are ineligible for cost-plus reimbursement, but too small to thrive under traditional Medicare PPS. The demonstration actually started in 2004 and was slated to fade into the sunset, but it was given an extra life thanks to the ACA.

CMS earlier this month started naming the 20 hospitals that will participate in the program, including Grinnell Regional Medical Center and four hospitals in Maine. Only time will tell how effective the program is in addressing the financial strain facing rural hospitals, a strain that is very likely to grow in the coming years. A new TrendWatch report released earlier this week by the American Hospital Association peers into the unique challenges facing rural hospitals in a post-recession, post-reform era. "The recent economic downturn put additional pressure on rural hospitals as they already operate with modest balance sheets," the report states, noting that rural Americans are more likely to be uninsured and have lower incomes than those in the city. While the ACA expands coverage to 32 million people, "many rural hospitals will have to make upfront investments in order to handle the influx of new patients." The report goes on to point out that "limited financial and workforce resources present significant ACA implementation challenges for rural hospitals. As more rural Americans gain access to health coverage through Medicaid and the commercial markets, rural hospitals will experience greater patient demand that may strain already limited staff and capital resources."

It's not all doom and gloom though. The TrendWatch points out that the ACA boosts aid and services to rural communities. For instance, $1.5 billion for the National Health Services Corp for scholarships and loan repayment for primary care practitioners who work in health professional shortage areas. The law also extends outpatient hold harmless provisions for rurals. Still, there's ample concern that rurals will not be able to fully participate in some of the law's most substantial delivery system reforms, including accountable care organizations and value-based purchasing.

I'd encourage you to take a look at the TrendWatch. It is an enlightening read about one of the nation's most critical safety nets.

Email your thoughts to mweinstock@healthforum.com.

After two years of buzz and hype, this week marks the beginning of attestation for CMS's Meaningful Use EHR incentive program for hospitals, doctors and other providers, and the health care blogosphere is full of discussion on how hospitals can meet at least 19 of the 24 meaningful use objectives for hospitals and, if all goes right, start receiving additional reimbursements later this year.

In my interviews and informal conversations this year, meaningful use is second only to ACOs in frequency as a topic—and in the breadth of opinions I've received from both boosters and skeptics. Unscientifically, I would say a majority of the folks I've talked to take the general view of William Bria, M.D., CMIO of Shriner's Hospitals for Children, who sees meaningful use as a once-in-a-lifetime opportunity for hospitals and docs to invest in IT in a way that will lead to real clinical changes.

"It's a clear signal that there's been enough discussion…that the practice of medicine and the use of information technology should be integrated," Bria told me in a recent interview.

That's the ideal result, of course, and having written about many a tricky or initially unsuccessful IT rollout, I know hospitals will have plenty of challenges to navigate with doctors, vendors and staff as they aim for meaningful use. And that's why, for at least the initial round of attestation that starts this week, many prominent health care systems are opting to wait on applying for meaningful use funding until they're confident of meeting the requirements.

Part of the reason for the caution that I've been hearing lately is the requirement that applicants demonstrate compliance for 365 days. In practice, that means that hospitals and systems seeking to enter the program this year have to be perfect from Oct. 1, 2011, to Oct. 1, 2012. Hospitals are also concerned about meeting Stage II meaningful use requirements, which CMS released in draft form earlier this year and will take effect for 2013 and 2014.

John Frownfelter, M.D., CMIO of inpatient services for Henry Ford Health System in Michigan, told me in a recent interview that concerns about complying for a full year starting in October led to Henry Ford's wait-and-see approach.

"If we were to attest this year and start with a 90-day period this year, which is what's required, the next fiscal year requires we're perfect for 365 days, and that begins Oct. 1," Frownfelter said. By waiting a year, Henry Ford and other systems that decide to wait remain in the program's grace period, and will still qualify for full meaningful use payments.

"Starting this year, it doesn't bring inherent value, as long as we're on a long-term track that's safe," Frownfelter said.

Of course, waiting on a large infusion of federal cash isn't something that all hospitals are in a position to do.

"Mid-market facilities…are really depending on that money to show up in order to fund the technology initiatives they're going after," Spencer Hamons, corporate project manager for the Yukon-Kuskokwim Health Corporation in Alaska and formerly a CIO at San Luis Valley Medical Center in Colorado, told me in a recent interview. Is your hospital system moving ahead with attestation this week, or have has a decision been made to hold off until 2012? Email your thoughts to hbush@healthforum.com.

Kids say the darnedest things. So do certain management types, though precociousness is not nearly as endearing in people who ought to know better. That's evident in some of the responses I got to my question about what health care leaders can do to overcome friction among staff members of different generations. Clearly, for many the first step is to take a close look in a well-lighted mirror. A few cases in point:

• "I've heard leaders in a group of people say, ‘Turn up your hearing aid, Barbara,' when a woman in her 60s asked that a question be repeated. And, ‘Let's hire the young one—young people will work harder. He's just waiting for Medicare to kick in so he can retire.'"

•"When I suggested to our CEO that we move the supplies closer to the patient rooms, he told me to ask the young people to get them if my legs couldn't handle it anymore."

•"In a board retreat, the younger generation of physicians and employees were criticized for not being as committed and not working as long hours—a bit disheartening to the two gen Xers in the room (me and our CFO), who consistently put in very long hours to ensure the success of our organizations."

•"Another supervisor was planning an after-work get-together for our staff and I overheard her tell one of the new nurses she didn't need to come because she must have better things to do with her young friends."

• "He's clueless," one executive said of a C-suite colleague with a chronic case of foot-in-mouth disease. "And then he's surprised when some of these incidents end up in HR."

The good news is that there are authentic leaders out there conscientiously trying to bridge the generational divide. And there's plenty of advice to go around for the rest:

•"Managers need to lead by example and examine their own prejudices."

•"Leaders need to recognize that they have biases like everyone else and not be afraid to put them on the table for discussion, using respect and pursuit of perfection principles."

•"Talk about it. Acknowledging that generational differences exist is the first step in bridging the gap."

•"They need to build off our common commitment to patient care so we can all see we're on the same team, we just play different positions."

•"They need to stop telling staff what to do and start encouraging staff to take ownership of how we work together."

•"Environments need to be created that foster and encourage partnership and collegiality."

•"Managers need to identify key leaders (younger and more mature staff) and have them model a behavior of partnership."

•"Communication should be adjusted to be maximally effective. A generation that texts and tweets will not want to read an article or listen to a lengthy discussion about a new change."

•Conversely, "Managers can't communicate with their workers through social media alone. Older workers might not be as conversant in it, and it isolates the manager from his staff and the staff from their colleagues. I've designated two e-mail- and Facebook-free days every month because face-to-face interaction and encouraging everybody to honestly participate in a conversation promotes trust, camaraderie and teamwork."

Encouragingly, writers from a number of different hospitals described panels of executives, middle managers, physicians and staff who have come together to first understand and then work to overcome the generational divide in their own units, departments and across whole organizations.

"Our employee diversity committee has begun a series of lunch and learn opportunities to build awareness and dialogue on issues of equity, inclusion, fairness and respect," one writer related. "One of our first topics, scheduled for May, is embracing generational differences."

Like the pizza for peace summit one reader shared a couple of weeks ago, a diversity committee sounds to me like a simple step in the right direction. Do you agree?

My column, touching directly or indirectly on generational issues affecting American health care, appears in this space every Tuesday. I appreciate hearing from readers about these or any topics of interest to folks who work in hospitals. Send your thoughts to bsantamour@healthforum.com.

Today, in what will become a regular H&HN Daily feature, I'm handing the blog over to my readers and their thoughts on recent blogs, articles, podcasts and videos:

Robert Sigmond responds to Emily Friedman's recent piece on the 25th anniversary of EMTALA and its long-term impact:

"When I started working with hospitals in the 1940's on the Pennsylvania Hill-Burton plan, none of the hospitals that I remember ever charged for service in the Emergency Department. When I took my wife to the Emergency Department at the hospital of the University of Pennsylvania in the middle of the night with a terrible toothache back then, there was no way that I could pay for the care. The staff explained that they were not allowed to take tips! By the 1950's, Hill Burton requirements and the rapid growth of prepayment plans and the early insurance offerings had started to change all that, even before Medicare and Medicaid in the 1960's."

Debra Gerardi, R.N., writes in response to How to Build an Effective Accountable Care Organization, written by Abe Levy, M.D., Aric Sharp and Scott Hayworth, M.D.:

"Adopting a proactive approach to conflict management and improving conflict competency among leaders will be a necessary component of any successful ACO. In addition, the Joint Commission has required this as a component of accreditation and as such it is an invitation to leaders to think of conflict management strategically as a core component of achieving overall safety and high quality care for patients."

On Don't Use That Kind of Language Here, a blog I wrote about the importance of clearly written signage, pamphlets and forms for patient communication, Cheryl Allen, R.N. writes:

"I've been an R.N. for 30 years, and sometimes when I go to the doctor I have no idea what they're asking. The form says have you ever had any of the following...Rash, well who hasn't had a rash? Do they want me to put yes—even though it only lasted three days or do they want me to put no because it wasn't significant?"

Scott Mason responded to Dan Beckham's article CEOs Under Scrutiny, about the changing expectations hospital boards have for their CEOs:

"Rather than punt to a health system in the absence of a thoughtful strategy or simply put off succession planning, progressive boards may be required to embrace non-traditional models in the selection of their future leaders. It has long been the model in healthcare for CEOs to come up through operations. This has worked to a point. But it is my observation that operations has very little to do with strategy; there is almost no crossover. Future CEOs in healthcare, as Dan noted, must be strategic. And to the extent that operations is important, it may be more a need for familiarity with physician practice and freestanding ambulatory operations (growing) rather than just hospital operations (shrinking). At the same time, we should not forget that ‘culture eats strategy for lunch.'"

And finally, Daniel Fell, from Chattanooga, T.N., responded to How CIOs Can Stay Relevant, a podcast interview with Spencer Hamons, corporate project manager for the Yukon Kuskokwim Health Corporation in Alaska, on the importance of CIOs in smaller markets:

"I think one way CIO's can break out of the IT silo is to collaborate with departments like marketing who have a shared interest in IT solutions. Marketing also brings a broad market and customer perspective that can help IT to be more successful in its planning and implementation efforts."

Send your thoughts on any item to hbush@healthforum.com.

In today's Data Snapshot, we're highlighting a CDC report out this week finding that 52 percent of Americans used at least one dietary supplement on a regular basis between 2003 and 2006, up from 42 percent between 1988 and 1994. The report tracked U.S. use of dietary supplements by gender as well as ethnic and age groups. Among the other key findings:

• Roughly 39 percent of Americans reported taking either multivitamins and multiminerals, up from 30 percent in the previous study and the most common dietary supplement reported taken.
  

• The number of Americans taking supplements with vitamin D increased for men and woman in nearly all age groups.

• Overall 60 percent of women over 60 report taking a dietary supplement containing calcium.

• Non-Hispanic white women were approximately twice as likely to take one or more dietary supplements containing folic acid than non-Hispanic black and Mexican-American women.

Read the full report here.

Would you be more likely to put down that French fry and pick up a carrot stick if you knew that your health insurance policy didn't have a deductible? Would you hit the gym more often if your insurance premium were waived? And what if you didn't have to pay for smoking cessation classes? Would you be more likely to snuff out the habit?

Federal health officials are hoping the answers to all of those questions are a deafening "Yes" from Medicaid beneficiaries. CMS earlier this month started accepting applications from states for $100 million in grants to reward Medicaid beneficiaries who quit smoking, lose weight, exercise, keep their blood pressure or cholesterol under control, and more. The Medicaid Incentives for Prevention of Chronic Diseases Program was mandated by the Affordable Care Act. In announcing the grant application period, which ends May 2, CMS said the goal is to "test and evaluate the effectiveness" of providing "financial and non-financial incentives to Medicaid beneficiaries of all ages who participate in prevention programs and demonstrate changes in health risk and outcomes, including adoption of healthy behaviors."

A guidance document put together for CMS by Thomson Reuters says the program should not be about giving people money. Rather, it should include incentives such as waiving premiums, deductibles and coinsurance payments. States could provide points that could be used to buy medications. Beneficiaries could be reimbursed for taking smoking cessation classes or Weight Watchers. The guide also discourages the use of penalties, calling them counterproductive.

"Penalizing beneficiaries for not participating in health improvement programs or achieving certain health outcomes will instill resentment and likely negatively impact the most vulnerable beneficiary populations," the guide states.

That's not necessarily how Arizona Gov. Jan Brewer sees things. She's taking the stick approach. The Republican governor proposed a $50 annual fee for adults who smoke. Similar penalties would apply to obese or diabetic beneficiaries who fail to follow a physician's treatment plan.

Importantly for providers, the CMS guidance suggests that state activities be done in conjunction with existing care coordination projects, including patient-centered medical homes and ACOs. To be clear though, the financial incentives are for beneficiaries, not providers.

The jury is still out on how effective incentive programs are in getting people to adopt healthful lifestyles and/or better manage their chronic conditions. But with Medicaid at the center of the budget debate boiling over in D.C., it's clear that health professionals need to utilize any and every tool at their disposal. That cost curve isn't going to bend all by itself. Treating diabetes alone accounts for $174 billion in direct and indirect health care costs. Multiple that by other chronic conditions such as congestive heart failure or high blood pressure and, well, you see where I'm headed.

It'll be interesting to see what kind of programs states bring forward. And isn't it kind of refreshing to think about a government health program spending money in the hopes of making people more healthy, rather than solely focusing on Medicare and Medicaid's looming billion dollar diet?

I'll continue to explore issues of wellness and prevention in upcoming blogs and certainly welcome you take on how we can bend the cost curve. Send me your thoughts at mweinstock@healthforum.com.

(Editor's note: H&HN Daily Regular Contributor Emily Friedman is guest blogging today.)

AMSTERDAM—Last week, I had the privilege of speaking at the International Forum on Quality and Safety in Healthcare in Amsterdam, Netherlands, cosponsored by the Institute for Healthcare Improvement and the British Medical Journal (BMJ) Group. There were nearly 3,000 attendees from 86 countries; several thousand more watched via satellite.

Rein Willems, the retired president of Shell Netherlands, now a member of the Dutch Senate, in his keynote address spoke of "blame-free error reporting"—systems that allow or require reporting of all adverse events, without blame or penalty—and asked why health care systems are so reluctant to adopt this approach when it is used widely in other sectors. Americans might say that the reluctance is due to potential malpractice litigation, but it's a problem in health systems around the world, including those where lawsuits aren't much of an issue.

Two compelling sessions focused on disaster. Afghan physicians spoke of progress made despite years of Taliban oppression and war. Dr. Nadera Hayat Burhani, deputy minister of health, emphasized culture change: "We need to break learned helplessness on the part of [hospital] staff." She also reported that Afghanistan has gone from relatively few midwives to 2,000 (critically important in a country with the second highest maternal mortality rate in the world), and that 22,000 community health workers have been trained. The most moving moment came when Dr. Nasrine Oryakhail, director of Malalai Hospital in Kabul, marveled that ten years ago, she could not leave her home without permission, and now she was addressing an international audience.

A Skype broadcast of two physicians in Fukushima Prefecture, Japan—the center of earthquake, tsunami, and nuclear power plant damage—was riveting. Dr. Ryuki Kassai, a community physician and professor, and Professor Shigeatsu Hashimoto of Fukushima Medical University Hospital (FMUH) said that the hospital did not suffer structural damage, but its water and electric supplies are severely limited.

Five hospitals were destroyed by the quake and tsunami; their patients were transferred to FMUH, as were patients from a hospital near the power plant. FMUH is screening transferred patients, local residents, and plant workers for radiation exposure. About 500 have been screened; 10 were decontaminated, and two nuclear plant workers who suffered burns from highly radioactive water were treated. FMUH also brought in an expert on radiation risk from the Nagasaki University School of Medicine to educate staff and counteract rumors.

Dr. Kassai and Dr. Hashimoto expressed their thanks for words of support and prayers from around the world, which, they said, encouraged them and their colleagues to persevere.

"Please think of us," Dr. Kassai said.

The BMJ has made the broadcast from Japan available on its web site.

Emily Friedman

Independent Health Policy and Ethics Analyst

WASHINGTON, D.C.—The toolbox is full. The science is ready. All we need to do now is decide to do it.

That was the message CMS Administrator Don Berwick delivered yesterday when he and HHS Secretary Kathleen Sebelius made a last-minute appearance together at the American Hospital Association's annual membership meeting in Washington, D.C. They came to ballyhoo the Partnership for Patients: Better Care, Lower Costs initiative launched with great fanfare earlier in the day.

Spearheaded by HHS, the public-private Partnership aims to improve patient safety by widely sharing real-world examples of how organizations have reduced errors and encourage others to adopt those best practices.

"We know safety can be improved because hospitals are already doing it," Sebelius told AHA members gathered in the Washington Hilton. "Unfortunately, many of the proven methods have been slow to spread."

The Partnership sets two goals to be reached by the end of 2013: reduce preventable hospital-acquired conditions by 40 percent and reduce avoidable readmissions by 20 percent. Up to $1 billion in Affordable Care Act funds will support the program.

Achieving the goals will not only save lives and prevent injuries to millions of Americans, Sebelius told AHA members, it could also save up to $35 billion dollars across the health care system, including up to $10 billion in Medicare savings, over the next three years. During the next 10 years, it could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings.

AHA President and CEO Rich Umbdenstock reassured the audience that the Partnership is a voluntary effort. "It's not changing the dates or penalties of the Affordable Care Act," he said.

"There's no down side," Umbdenstock stressed, noting that the AHA and five other national hospital associations were among the first to sign on, jointly pledging themselves to help the Partnership achieve its goals. Sebelius said 500 hospitals across the country had already pledged to participate as of yesterday afternoon.

Patient safety is not a workforce issue, Berwick said, "it's a property of a system," that may, for instance, be too complex, too fragmented or that uses poor technology. Improving it depends on leadership—from the board of trustees to the C-suite to clinical executives.

The Partnership "takes excellence to scale," Berwick said, in order "to make the best care, normal care."

Sebelius said the initial targets are just the start. "Our ultimate goal in health care should not be to reduce errors by 10 percent or 20 percent or 30 percent," she said. "It should be to eliminate errors."

For more information, click here.

WASHINGTON, D.C.—"Of all the introductions I've received, that was the most recent," former Sen. Alan Simpson remarked as he took the podium Monday at the American Hospital Association's annual membership meeting. Simpson gave a wry, often laugh-out-loud review of his work on the National Commission on Fiscal Responsibility and Reform, a nonpartisan panel appointed by President Obama to come up with a strategy to reduce the nation's debt.

Simpson, a Republican, led the panel along with Democrat Erskine Bowles. Their plan was unveiled in December and immediately set off a fury of condemnation from all points along the political spectrum. It recommends, among other things, significant changes to entitlement programs as well as a three-tiered income tax and tweaks to corporate taxes. The White House response up to now has been muted to say the least, but speculation here in Washington this morning is that the Simpson-Bowles proposal will, in fact, be the basis of the deficit reduction strategy the president is slated to unveil tomorrow.

Of all the government spending issues his commission tackled, Simpson said, "We found health care to be an absolute monster. It's the biggest fiscal challenge that our nation will ever see." If Americans are serious about getting the federal budget under control, "you can't get there without cutting Medicare, Medicaid and Social Security," he declared. "Anyone who tells you otherwise is a fraud."

Criticism of Medicare and Social Security reform is "bilious babble," Simpson said, noting that 10,000 baby boomers retire every day, the average life expectancy has climbed from 63 to 78 since Social Security was introduced, and as of May 2010, Social Security paid out more than the amount put into the program.

But balancing the budget can't happen by cutting alone, he said. "Ronald Reagan raised taxes 11 times. Why do you think he did that? To keep the government running."

Simpson said his commission's plan was "written for the American public" in plain English and is just 67 pages long. You can read it here.

I've heard a lot of interesting speakers and had conversations with a lot of attendees from hospitals around the country during the AHA annual meeting. Many of the issues discussed revolve around generational issues, including aging patients, physicians, nurses and hospital leaders. I'll share some of what I've heard in that regard on upcoming Tuesdays in this space.

Last Friday, HHS released a five point action plan to address racial and ethnic disparities, the latest sign that hospitals, the federal government and other health industry leaders are making a strong push in this critical area. The HHS report calls for, among other things, expanded insurance coverage, new service delivery sites to better serve patients and the increased use of patient-centered medical homes. The report comes as the Joint Commission is on the verge of implementing its own standards around patient-centered communication—a key element of disparities reduction efforts—next year.

My sense is that as efforts intensify nationally to control health care costs, health care leaders are beginning to see disparities work not just in the context of delivering equitable, high-quality care to all patients, but as a key prong in the overall battle to reduce the high costs associated with patients with multiple chronic conditions. The HHS disparities plan, for instance, specifically notes the presence of disparities in care in cardiovascular disease, childhood obesity and tobacco-related diseases, and recommends targeted efforts in these diseases as part of its overall approach.

That approach—viewing disparities not so much as an isolated area of focus but as a critical component of an integrated quality strategy—was championed by the subject of today’s HHN Daily video interview, Joseph Betancourt, M.D., director of the Disparities Solutions Center who also works as a primary care physician at Massachusetts General Hospital in Boston. Betancourt talked up a Mass General program in Chelsea, Mass., that employed a bilingual health coach to improve adherence to diabetes treatment regimens and, ultimately, patient control of the disease. The presence of the coach helped reduce disparities in care for Hispanic patients, but also improved diabetes outcomes for all patients in the program regardless of race or ethnicity, all of whom benefited from the coach’s instruction.

Reducing disparities can be daunting work, of course, and requires a great deal of detailed information. When I interviewed Maulik Joshi, president of the AHA's Health Research Educational Trust, last week to discuss HRET’s new report, Improving Health Equity Through Data Collection and Use, he stressed the importance of engaging all staff around the critical first step of acquiring patient data around ethnicity and language, which, given its sensitive nature, can pose a major hurdle.

In the years to come, directives from the Joint Commission and HHS on disparities reduction will force providers to get in the game. And with the innovative work already going on in the field as inspiration, I'm increasingly optimistic that disparities reduction work is moving from an isolated area of hospital operations to a central component of overall patient care strategy.

A report this week in Health Affairs finds that adverse events occur in 33.2 percent of hospital admissions, or 91 events per 1,000 patient days. Those rates are considerably higher than previously suspected, the authors argue.

The researchers, funded by the Robert Wood Johnson Foundation, used the Institute for Healthcare Improvement's Global Trigger Tool as a guideline for discovering adverse events. According to the report, traditional event detection methods, including AHRQ's Patient Safety Indicators and voluntary reporting, may miss up to 90 percent of adverse events.

In a statement, AHA President and CEO Rich Umbdenstock said hospitals are dedicated to improving patient quality and safety to prevent adverse events. "Hospitals are actively engaged in quality improvement efforts and are eager to identify and use strategies and tools that can further improve patient safety," he said.

On average, patients experiencing adverse events were older, had greater hospital length of stay and a higher case-mix index than the norm, the study also found. Read the full report here.

I never thought that I would actually say this, but a spokesman for McDonald's is right.

The other day, a New York City councilman introduced legislation that would prohibit handing out toys or games with any meal that doesn't meet certain nutritional guidelines. Fines would range from $200 to $500 for the first offense. Similar bills have been proposed nationwide. San Francisco lawmakers enacted just such an ordinance last year.

Mason Smoot, vice president and general manager for McDonald's New York region, issued a statement saying that taking toys out of Happy Meals won't solve the childhood obesity epidemic. He noted that kids eat the majority of their meals away from fast food restaurants. "That adds up to a larger discussion than toys," he said.

Smoot is right. Toys are not the issue. Don't get me wrong, I am not one to defend McDonald's and its impact on America's ever-growing waistline, but as I've written in the past, banning toys from Happy Meals is hardly a long-term solution to our penchant for unhealthy eating. Now I know that the big news this week isn't the debate over putting a plastic Superman in with your kid's chicken nuggets. CMS' proposed ACO regulations and the budget showdown that threatens to shut down the government are top of mind, and rightfully so. But, a larger, more thoughtful and reasoned discussion about attacking the nation's obesity epidemic is absolutely something we should have as we test new ways to deliver care and attempt to curtail runaway deficits.

The Centers for Disease Control & Prevention in 2009 issued a report showing that the increased prevalence of obesity added $40 billion in medical costs between 1998 and 2006, including $7 billion in Medicare prescription drug costs. Obesity was responsible for 9.1 percent of annual medical spending, compared to 6.5 percent in 1998. CDC went on to predict that total annual costs for treating obesity would climb to $147 billion by 2008, up from $78.5 billion in 1998. The National Bureau of Economic Research in 2010 pegged the number at $168.4 billion or 16.5 percent of medical costs.

From other CDC data, we know that 6.5 percent of children aged 6 to 11 were obese in 1980. In 2008, it was 19.6 percent. Among teens, the percentage soared from 5 percent to 18 percent. Obese youths are more likely to develop risk factors for cardiovascular disease and diabetes. They are at greater risk for bone and joint problems, as well as sleep apnea and psychological problems.

The problem is so much more complex than Happy Meals. It crosses almost all socioeconomic issues—education, jobs and the economy, economic development. Hospitals can't control many of the leading causes of obesity. Instead, they have to deal with the effects. Until we take a holistic approach to addressing the obesity epidemic, there will be little bend in that cost curve they are talking about in Washington, D.C.

In the year since the passage of the Affordable Care Act, Medicare's Accountable Care Organization program, or partnerships between providers designed to improve cost and quality in exchange for shared savings, has been one of the most-talked about components of the bill, especially within the industry. The fever pitch to join an ACO has even been parodied on YouTube, a telltale modern sign of the idea's popularity and reach.

After months of waiting—and with the Jan. 1, 2012, start of the ACO program looming, CMS finally released the 429-page proposed ACO rule last week. Among the big takeaways: CMS estimates that 75 to 150 ACOs will be formed, serving between 1.5 million to 4 million Medicare beneficiaries over the first three years of the program. Simultaneously, the FTC and DOJ released a proposed statement on antitrust enforcement policy as it relates to ACOs.

All this week, I've been surveying reaction to the rules, and the consensus seems to be that there were no major surprises in the rule that weren't apparent from reading the relevant portions of the ACA last year. Still, there are plenty of differing opinions out there to digest, and I've compiled a few of them that caught my notice:

• Fiercehealthcare.com surveyed the health care industry and labeled the general reaction to the rule as one of "cautious enthusiasm."
  

• In an interview with Health Leaders, Paul Keckley, executive director of the Deloitte Center for Health Solutions, said the main idea emanating from the guidelines is the promotion of physician-hospital alignment. "…You step back and see they are compelled by the vision of integrated systems," Keckley said. "That to me is the big cake here."


• Over at The Health Care Blog, Vince Kuraitis, principal and founder of Better Health Technologies, concluded that the rule was "surprisingly aggressive and well-reasoned." Kuraitis called the Antitrust Enforcement Policy notice a sign that "concerns over maintaining competition and avoiding antitrust are being taken seriously." Kuraitis also had words of caution for organizations thinking of applying that may not be entirely ready to participate. "The bar has been set high…very high. Tire kickers need not apply."

• Paul Levy, former CEO of Beth Israel Deaconess Medical Center, and author of the now Not Running a Hospital blog (formerly Running a Hospital), took issue with the fact that providers cannot require beneficiaries to obtain services from other providers. "How can you be held accountable, as a provider group, if you cannot control the management of care of your patients?" Levy wrote.

• Jeremy Lazarus, M.D., speaker of the AMA House of Delegates, told American Medical News that all physicians who wish to participate should have the opportunity to do so. "ACOs offer great promise for improving care coordination and quality while reducing cost, but only if all physicians who wish to are able to lead and participate in them," Lazarus said. That will certainly be an issue; as I wrote earlier this week, some observers believe not all ACOs will have the capacity to absorb all interested parties.

• And finally, Eweek.com reported that the legislation poses a challenge for IT vendors who will need to create systems that can distribute shared savings and share data among providers.

Send your take on the Proposed ACO Rule to hbush@healthforum.com.

One of these Tuesdays, I'll report back on the responses to my question about what hospital leaders can do to overcome friction between staff members of different generations. First up, I wanted to share this example from a senior executive at a small hospital in the South.

"I was made aware of hard feelings between two baby boomer staff nurses and two recent hires just out of nursing school," she told me. "I decided to meet them in a neutral location so we could clear the air."

She chose the pizza place across the highway from the hospital. The nurses arrived separately in pairs according to age, and the two pairs slipped into opposite sides of the booth. The executive pulled a chair up to the end of the table.

She asked what they wanted on the pizza. One of the boomer nurses said she liked pepperoni. One of the Generation Y nurses said she was a vegetarian and asked for mushrooms. The other older nurse said mushrooms upset her stomach and if pepperoni was out, they should just get a plain cheese pizza. The other younger nurse said she was on a diet anyway and would just have the house salad.

Listening to the back-and-forth and trying her darnedest to hold it in, the executive finally burst out laughing. Nonplussed, the four nurses drew back in their seats and exchanged wary glances. Then, one by one, they joined in.

"We sat there like lunatics laughing helplessly for five minutes," the executive recalled. "The poor waiter was afraid to come over to take our order. When he did get up the nerve, I asked for two medium pizzas—one with pepperoni, one with mushrooms—and house salads all around." As soon as everyone had regained her composure, the executive leaned forward and said, "OK, now that we've settled the Pizza War, what can we do about work?"

And so began a 45-minute discussion, sometimes heated, but mostly not, about everything from scheduling of shifts to job assignments to office etiquette and behavior toward colleagues. "When we got to the topic of actually dealing with the patients, I was a little nervous," the executive admitted. "I thought it would be between ‘this is the new way we were taught in school' and ‘we've always done it this way here and it works just fine.' "

Instead, a younger nurse confessed that she sometimes felt overwhelmed by the workload and didn't know if she'd ever be able to juggle so many different tasks. An older nurse sheepishly acknowledged that she'd felt the same way her first year or so on a patient floor.

"That was the turning point," the executive said. "The ice was broken." Soon enough, the younger nurses were asking the baby boomers if they had any tips for sorting out the work a little more efficiently, and the boomers were asking if their co-workers could help make sense of some of the new technology.

"Let's face it, these nurses will never be the closest of colleagues," the executive said. "But the defensiveness and anger are pretty much gone."

What do you think? Can the generational conflicts at your hospital be tempered with a little pizza diplomacy? Tell me at bsantamour@healthforum.com.

By the way, I'll be in D.C. for the American Hospital Association Annual Membership Meeting starting this weekend. If you're around, look for my name tag and introduce yourself. I'd like to meet you and hear some of your real-life experiences working in a hospital—whether they relate to generational issues or not.

MIDWAY, UTAH—During last week's CMS announcement of the proposed rules for accountable care organizations, or ACOs, I was, appropriately enough, in Utah's Rocky Mountains at the Intermountain Healthcare Clinical Quality and Accountable Care Seminar. Intermountain, with its own insurance plan and medical group, is designed to deliver clinical best practices in every patient encounter and is often held up as one of the models for ACOs. The seminar was billed as a chance for other hospitals to learn how all the pieces fit together.

But while Intermountain leaders were happy to discuss their efforts to root out variation, partner with physicians and manage population health initiatives, they were generally cautious about the comparisons between the ACO program and their system, which has evolved gradually since it was created in 1975 as a non-for-profit organization inheriting 15 hospitals previously run by the Church of Jesus Christ of Latter-day Saints.

When I talked to Intermountain CEO Charles Sorenson, M.D, he took pains to point out that many of Intermountain's key assets—an EMR that gives doctors best-practice information at the point of care; its in-house insurance plan, Select Health; and its close relationships with doctors—took years of fine-tuning and negotiations to get right. And Linda Leckman, M.D. CEO of Intermountain's Medical Group, had words of caution about the ACO model's emphasis on clinical integration, during a session on alignment between the medical group and individual physicians. Sometimes, hospitals simply don't have the capacity to hire or affiliate with every physician who would like to join, Leckman pointed out.

"Nationally, speakers are telling physicians that in the next three years, you need to be tied to an ACO," Leckman said. "In our community, there are physicians who want to be a part of us, but it doesn't always work for us. The more clinicians you have, the more your infrastructure gets stretched."

On the final day of the seminar, Greg Poulsen, senior vice president of strategy for Intermountain, drove home the importance of the work that ACOs and independent care coordination efforts, like those at Intermountain, will have to deliver in the years to come. Poulsen briefly surveyed the current political machinations around the ACA, and then argued that regardless of how national reform plays out, the challenge of bending the ever-rising health care cost curve will remain. Poulsen noted that future, unfunded obligations to Medicare are estimated by the GAO at roughly $37.9 trillion—dwarfing unfunded obligations to the national debt and Social Security.

"This is a big problem if the growth rate continues," Poulsen said.

Despite that grim forecast—backed up by a flurry of statistics on variations in health care outcomes and utilization—Poulsen sounded a somewhat upbeat call to the hospital leaders and doctors who trekked out to Utah to look for solutions.

"Can we change the health care cost structure to make things better?" Poulsen asked the audience.