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.