Have you noticed the number of hospital expansion projects in your area? Odds are quite good that you have. If not, read here, here, here, here, here, and here. That’s a small sample.

I realize that some hospitals have finally reached a strong enough financial position and can now expand after putting off the need for years. And that our population is aging: to prepare we need more capacity.

What if the expansion is due to a medical arms race? A Health Affairs article says, “Hospitals are increasing capacity in high-end and high-volume product lines, to compete with other hospitals and freestanding outpatient facilities.”

That makes sense financially, but is not necessarily good for the patient.

What are we going to do with all the capacity when the retirees are no longer so numerous? Another Health Affairs article says, “Ultimately, a great deal of added cost to the health care system will result from recent construction activity, some of which might be attributable to costly duplicative and underused capacity.”

And this should be sobering. This article in the Journal of the American Medical Association says that when a cardiac hospital opens, heart surgery in the Medicare population within that community increases. In other words, capacity creates demand. If things stay the same (doubtful, I know…but for the argument’s sake) we won’t need to worry about excess capacity because those beds will be filled…potentially with patients who really don’t need to be there.

I’m all for hospitals growing with a purpose, it just scares me of the managerial (and cost!) problems these expansion projects could leave us with in 30 years.

Some good reading related to hospital expansion.

Medicare’s Diagnostic Related Group (DRG) classification system changed (again) recently.  My (basic) understanding of the change means better reimbursement for hospitals (specifically academic medical centers) and less reimbursement for ambulatory surgery centers (ASC).

ASCs have been criticized in the past for operating on the best cases (low complications, highly reimbursed procedures, some even call 911 if complications arise during surgery because they don’t have emergency capacity).  However, an argument on the efficiency impact can’t be ignored.  The learning impact for providers who operate on similar cases on a daily basis should raise quality, something we obviously need.  The majority of patients who receive services from ASCs do just fine.

Regardless of what actually was intended by the DRG change or what happens in the future, what are your thoughts on ASCs?  Is the service they provide a benefit to our health care system?  Are they taking business away from hospitals?  Do they force hospitals to be more efficient? (As always this gets a little more complicated than asking a few simple questions: I think some other issues are at work here like physician ownership and referral patterns.)

Whether it is a function of less access to primary care physicians or the importance of the always-burgeoning internet…Web 2.0 has hit health care. Actually, this post is pretty late to the party…

What is Health 2.0? Go here. Some examples: iMedix, RevoultionHealth, Medstory, Healia, Xoova, Organized Wisdom, and (less 2.0 than the others) the industry’s gray lady: WebMD.

Its impact, I feel, to this point has been muted. But its time is coming. What will be the impact of Health 2.0 on health systems?

Hospitals will have to take into account the impact of these websites on the delivery of care. It is this notion of the
patient as a partner in the deliverance of care. Obviously it is the way it should be–patients participating in tandem with their providers.

But there are some consequences. With added knowledgeable in tow, more questions will be asked as patients feel better informed, which will increase the likelihood of lengthier conversations with providers. All good. But providers will need to spend more time with patients (like more than five minutes) and that means patient throughput will decrease. Given the current state of reimbursement in this country where we reward for more care, not better care, providers may not be able to see as many patients in the same amount of time.

Health 2.0 means changes for hospitals and providers, can we explore what some of them are?

BTW: adenoma.

Remember the days when a house visit by a physician was the primary way of caring for a patient?

The service seems to be making a comeback. It’s not just something they do in France, either (for those of you who have seen Sicko).

I have come across two websites (one–this service seems really cool–, two) in the past few days of physicians who are more than willing to make house calls (after seeing this story in the New York Times in September). For those types of illnesses that don’t require significant medical technology it can be a great thing. The issue, as always, comes with cost. In the (mostly) free market that is the United States health care system, that means those who are able pay for the house visits and individual attention, do so.

House visits are a great idea. We just need more physicians to start. And that means lowering the cost so that demand is greater. And that means the reimbursement function needs to be completely rethought. And that means…

I appreciate the innovation and would like to see the model continue to expand.

This caught my attention.

Healthcare Analytics is working on a “sort-of” medical credit rating the likes of which banks (and many other institutions) currently use to judge a consumer’s credit worthiness. Hospitals will use the score to determine patient’s likelihood of paying medical bills. The company says the score will only be used after care has been delivered.

Here’s my issue: patients often come back to hospitals/clinics. How are those hospitals/clinics going to prevent discrimination against patients who have had trouble paying bills in the past? Will treatment be refused? I know that is illegal in ERs but what about in the hospital or clinic setting? At the least, will low-score patients’ care be of the same quality as those patients with higher scores?

Some critics have raised security and privacy issues with the data. But this doesn’t concern me as much–I think workable solutions can be found to limit data and identity theft.

But some good: hospitals could better predict collection rates. And if this data could be used before a patient is treated, it would allow health systems to better allocate charity care instead of those charges ending up in the bad debt category on the balance sheet.

Here is some more.

Do you have any reservations?

A surprisingly popular story around the web this week was the policy implementation at Saint Mary’s Duluth Clinic in Duluth, Minn., to effectively ban any product (pens, clocks, clipboard, medical models, etc.) with pharmaceutical logos. All I can think about is the number of pens SMDC will now have to purchase…

I think it is a needed, ethical, step in the right direction. Removing the (however minute) influence these products may have on doctors’ prescribing patterns is a good thing, especially as we see more issues arise regarding the safety of some drugs. Forcing decisions to be made through the use of objective information is always a good thing.

The policy is outlined here in the Duluth News Tribune. Some banter here.

We’ve incorporated it here.

Thoughts?

We were discussing community benefit in class the other day. If you don’t know what community benefit is the Catholic Health Association’s website is a good place to start. This website goes more in depth. Basically (says Senator Grassley’s website) (it is my understanding that he started the look into community benefit in 2005) “providing community benefit is required for hospitals seeking and retaining tax-exempt status as charities.”

The CHA says community benefit includes the following:
-Charity care
-Government-sponsored indigent health care—unpaid costs of public programs (Medicaid, SCHIP, medically indigent programs)
-Community Benefit Services (I guess this is the extensive “other” category–dw)

And does not include the following:
-Bad debt
-Contractual allowances or quick-pay discounts
-Any portion of charity care costs already included in the subsidized health care services category
-Medicare shortfall (this can be included in other financial reports but not in a community benefit report)

But as far as I understand community benefit is not limited to just these broad categories…one of the issues is that exactly how to define community benefit is a matter of contention.

In 2005 there was a big uproar concerning the tax-exempt status of not-for-profit hospitals and whether or not they provide enough benefits to the communities they serve. Hospital associations around the country with the help of the aforementioned CHA quickly put together a reporting system to outline provided benefits. Some associations seem to be reporting an extensive amount of community benefit (I’m using CB from here on out).

The American Hospital Association deems the tax-exempt status of not-for-profit hospitals an “issue” but you have to be a member in order to access any releases (sorry, I’m on a student income and unable to afford such a luxury at this time so I can’t even summarize).

Since then, it has been rather quiet on the CB front. However, in July the IRS released an interim report (pdf) that apparently outlined a not-so-good effort by not-for-profit hospitals to provide CB. And most recently the IRS updated its Form 990 that not-for-profits use to claim their CB (side note: kind of ironic that a non-taxed entity submits forms to the government agency responsible for taxation. I guess someone has to watch over us…).

I’m sure this story hasn’t ended quite yet. CB is a very important function hospitals provide to the communities they serve. Hopefully the amount of CB provided won’t have to be mandated by the federal government…stay tuned.

Do you think hospitals currently provide sufficient community benefit (any examples)? What do you think is an appropriate policy for providing community benefit at our own system?