Every major project (worth doing) is unique! But there is no
“magic bullet” Project Management template. However, one way of starting any
project is by reaching a consensus on “anchor concepts” which can serve to keep
the project on track (and can be revised during the project).
Assignment: Your program is up for a CAHME accreditation
visit and you are chairing the “preparation” committee. What are the “anchor
concepts?
Following are some “anchor concepts” examples for different
types of projects:
In July of 2009 the Mayor of Hoboken asked me to initiate a H1N1
“Swine Flu” Task Force. We started with a set of questions based on reports
from communities that had already experienced a Swine Flu surge:
Health Officer: Where vaccination sites should be
established? Is there a special plan to monitor restaurants and food shops
where flu-related safety guidelines need to be strictly enforced? Who will
start preparing a Community Education plan?
Hospital: What is the back-up plan if hospital becomes
“contaminated” and is closed to admissions, or if nursing staff is
depleted by flu-related absenteeism, etc.? ICU triage? Availability of
respirators?
OEM: off-site
screening centers if hospital ER is on overload
Hoboken Volunteer Ambulance Corps: “mutual assist” plan
Hoboken Police Department & Hoboken Fire Department:
back-up plan if the ranks get depleted by the flu
BOE: criteria in deciding whether or not to close schools
Stevens Institute of Technology: surveillance and plan for
(college) students
“Field Manual” for the Mayor
An umbrella agency allocated money to 18 different Food
Distribution programs in three categories – “meals on wheels”, food pantries,
congregate meals – $1 million/ year; & separate pots of money for housing
stability, and aging in the community. There had been no review of the allocation
in ten years, just automatic renewals. There was no “organizational memory” on
why this program was initiated.
We started with some agency – Food Distribution Principles:
Agency is committed to providing basic supports to the most
vulnerable in the Jewish community.
Food insecurity exists within the Jewish community and the
Agency is committed to a programmatic response.
Funded food programs should reflect Best Practices in the
field.
Agency is committed to kashrut. (kosher
food)
In order to address the needs of all those who are
vulnerable, the relative size of needy groups should be considered in the
distribution of funds.
The rationale for continued Agency funding should be
clearly articulated if there are similar nearby programs with available
capacity.
Agency funded food programs duplicating similar nearby
programs should be open to merger opportunities.
Agency should provide kosher food to those who request it.
However given the higher cost of kosher food, a facilitating process
should connect those who do not require kosher food to other
accessible food programs.
Food programs funded by the Agency should be nutritionally
sound, fully compliant with their regulatory agencies, be certified or
accredited if there are certification or accreditation programs in place,
and be active members of industry associations.
Funded agencies should have and enforce an effective
Conflict of Interest policy.
A Health and Social Services Agency reviewed whether it
should change accreditation agencies. We started with a set of assumptions:
“Price” should not be the singular criteria to
change Accreditation. Neither should staff effort required.
HSSA should be in the main stream of Accreditation with
other similar leading HSSAs in the United States – this is not an area to be a
pioneer
Evaluation criteria should be developed first and then a
number of Accreditation alternatives should be reviewed
Only “Evidenced-Based” options should be
considered. “Best Practices” is not sufficient.
If and when the field is narrowed, HSSAs using these
Accreditation vehicles should be contacted for feedback
Any change should not in any way compromise the
“rebranding” initiative – check with our consultants
Make sure any change does not affect the professional
staff’s certification, licensure, and “credibility“
Make sure any change does not affect HSSA’s reimbursement
from any source
Be comfortable that any change will be acceptable to key
“funders
HSSA was considering new revenue streams, more specifically
“for profit” partnerships to support its NFP mission. So we started with Principles
for Social Entrepreneurship Projects – HSSA:
Projects must be consistent with (and enhance) the Mission
and Vision of HSSA
Our Mission: Guided by the wisdom and values of our
tradition of respect for all people, HSSA provides innovative, compassionate
and outstanding social services to enhance the independence and well-being of
individuals and families throughout all stages of life.
Our Vision: HSSA will be the premier Agency within the area
providing for the social services and mental health needs of the greater
community with unparalleled professionalism, humanity and respect for all who
seek its support.
Projects must not adversely affect the reputation, “brand”,
integrity, fund-raising capability or tax-exempt status of HSSA.
To the greatest extent possible HSSA should seek to identify
and replicate successful projects at other similar agencies.
Any new SEP should contribute at least $100,000 a year to
the Agency’s bottom line, within a 3 year start-up period.
Priority should be given to Joint Ventures where partners
provide start-up funding and take the financial risk and the Agency provides
its “name”, experience and reputation (and gets a lower but steady long term
income stream).
Project development costs must include the cost of staff
time on the project.
“Clients first.”
….who among us can escape the lonesome time? When hours are
as days. When the past becomes more real than the future. And thoughts of
getting old are replaced by the anxiety of feeling old. New generations move in
as old friends fade away. That’s the lonesome time. The time more than any
other when people need people. When people need to be needed.
Senior Camps was founded in 1969 to provide overnight
camping services to children and adults.
There were initially six summer sessions – each two-weeks
long, serving more than 1,400 people annually by 1976.
1982 was a very good year for the agency – more than 4900
people within 43 weeks of programming, including the summer programs, holiday
programs, children’s camping, and trips to Florida, California and Israel.
The agency was doing well financially in 1987 with $1,850,
000 in assets earning interest.
In late 1980’s, the agency began to run significant yearly
deficits in part because of the capital money being put back into facilities.
In 1991, the property tax was reinstated on both camps at an
annual cost of $66,000.
By 1993 the surplus dropped to $30,000.
Time for a new strategic plan…..
Possible Review Questions for Strategic Planning Committee –
May 6, 2010
1. Review evolution of Mission Statement over
time.
a) Does it need any reconsideration in light of the current
“sustainability” challenge?
b) What are Camp’s core values?
c) What is our vision for the future?
d) What defines camp? As a Vacation Center?
e) Does Camp actually offer (as the byline says), to
energize mind, body and soul?
f) Who is the actual Camp “customer”? Why do they
come?
g) Does Camp have a loyal customer base?
h) What describes a camping experience? A vacation
experience?
2. Profile the competition – location, program,
amenities, Jewish or secular, cost, “sizzle” etc – any easy
“copycatting we can do”?
a) What are essential facility upgrades to compete?
b) What are essential programs that we should look to add to
stay competitive? More active?
c) Can we play-up our spa concept/health and wellness?
3. What unique groups should be
targeted? Jewish? Secular? Special Needs? Special Interests? How can we expand our marketing efforts with
limited resources and staff time?
4. How do we find more groups to partner with in order to
sell our product wholesale?
5. How can we expand off-season use?
6. How many weeks of Senior Camping are necessary for
Camp to still be Camp?
a) Should we look at offering shorter/less defined stays –
i.e. more hotel like?
b) How do we become attractive to the Baby Boomers?
7. What are the impediments to successful Camp
fundraising?
8. Are there
grant-writing opportunities for tuition subsidies and/ or capital funds?
9. What’s in a name? Does Camps name work? no!
10. How do we define ourselves in terms of who we serve –
i.e. Orthodox, Conservative, Reform, non-Jews, etc.? How do we successfully
meet the needs of all of these communities?
11. Can we/should we expand our programming into the
Orthodox community?
12. Is there sufficient diversity on the Board to
address the current challenges?
13. Is Camp being actively marketed to other
affiliated seniors agencies?
14. Can the “Jewish” Internet be used
to market Camp?
15. How will we measure progress and success
(metrics)?
16. Should we consider running other travel programs?
17. Are there any Bylaw changes needed
(e.g., committee structure, attendance requirements, term limits)?
18. Should there be a special “free” weekend
for various JCC execs, other Jewish agency execs, Rabbis who can send
groups – so they can experience Camp?
Strategic Initiatives – June 2010
1) Mine affiliated
agencies for “wholesale” opportunities
2) Reach further into the Russian speaking
community, both for additional clients and for possible funding streams or
grants for scholarships
3) Identify possible alliances within the
Orthodox communities for both senior groups through the Young Israel Synagogues
and for programs to serve younger adults and families
4) Contact Aspergers, Autism and other special
needs organizations to test Camp’s special needs potential
5) Develop marketing plan for reaching families who
might hold family summer-camp sessions at Camp, such as reunion websites and
Grandparents.com, and email to USA-Federation email list
6) Explore joint ventures with non-northeast
synagogues, Ys and other institutions that might plan NE Jewish heritage tour
with a week at Camp
7) Research Grant opportunities from Jewish
family foundations
8) Develop donor list for annual donor
funding
9) Develop a marketing plan
using existing “best” Jewish web-sites and newsletters,
including separate web pages for each Strategic Initiative adopted
10) Presentations to Executive Director groups, e.g.,
Jewish Family Services, ED groups in New Jersey and New York
11) Identify changes made by successful senior camps
12) Is it time to change the name of Camp?
13) Board Self-evaluation
14) Recruit graduate program interns in various
fields to assist with the “leg work” and planning
“The Strategy” – Three Camps
Camp will be reorganized as 3 separate camp structures
Vacation Center – Our current program for senior adults
Camp for Adults with Disabilities
Retreat Center – More structure and outreach for our already
established retreat and rental program.
In April 1991, Hudson Cradle was started to help alleviate
the boarder baby crisis. Boarder babies are infants healthy enough to be
discharged from the hospital, but do not have a safe place to call home. Hudson
Cradle welcomed our first infant resident in March 1992. Hudson Cradle provides
care to approximately 42 babies each year. Hudson Cradle is licensed as a
Children’s Group Home
2007 Issues
Senior members on the Board of Trustees too long
New Board members join and then leave quickly
Need a Board/ management,
transition/ succession plan
No Strategic Plan
1. Mission: Is the
current Mission Statement still timely and appropriate?
2. JCMC Affiliation:
Is the current arrangement with JCMC still appropriate and working effectively?
3. Clinical Services:
Does HC provide an appropriate and Evidenced Based scope of clinical service to
the babies? Are formal affiliation agreements in place for each of these
clinical services if not available on-site?
4. Outcomes: Is it
agreed we need to better track outcomes while the babies are at HC Cradle and
after they leave?
5. Program: Should
HC expand its program scope beyond residential care? If so are there gaps in
care in Hudson County that HC might consider providing?
6. Cribs: do we have
data to demonstrate a real need for more cribs?
7. Space: how much
additional space is needed on-site for the current mission/ program?
8. Facilities: what
immediate facilities improvements are needed regardless of mission/program,
e.g., maintenance, life safely etc?
9. Disaster Plan: Is
it agreed HC needs Contingency Plans if the building needs to be evacuated?
10. Contingency Plan: Is it agreed that HC needs a
“baby transfer” plan if HC suddenly runs out of money?
11. Jersey City Medical Center/ Greenville: what, if any,
are the implications of the closure (or changes) to Greenville and the cutbacks
in pediatrics at JCMC?
12. Marketing Plan: why does HC need a Marketing Plan?
and/or
13. Development Plan: How can HC’s successful Development
efforts be expanded to include the local (Waterfront?) corporate sector?
HUDSON CRADLE – ’08 Strategic Plan (11/29/07)
A. Mission Statement
Hudson Cradle is a Group Home providing full, nurturing care
to homeless infants with special health and developmental needs (“boarder
babies”). In addition, Hudson Cradle provides counseling, education, and
support services to birth or foster parents to prepare them to live as a
family. Hudson Cradle also provides outreach and educational services to the
community.
B. Strategic Principles
1. Does the New
Jersey Department of Children and Families consider HC an essential Agency
“waivered” under the Court order? If so, will DCF agree to give HC 18 months’
notice of future discontinuation of referrals/ admissions? And, will DFC give
HC an enhanced reimbursement rate to support the enriched nurse staffing and
additional hospital visits necessary to care for the sicker infants being
referred?
2. HC will develop
and implement an Evidenced Based Outcomes Dashboard for current and future
services.
3. HC should expand
its Mission to include a range of non-residential community services to
infants-at-risk. What services should be considered?
4. While continuing residential services, and adding
community services, HC should consider becoming an Umbrella Organization for
mission compatible small not-for-profits in Hudson County.
5. The effectiveness
of the current contract with Jersey City Medical Center should be monitored as
the Medical Center continues it’s restructuring.
6. Contingency plans
should be developed given the announced closing of Greenville Hospital.
C. Facilities
1. Consideration of
moving to a new facility and/ or expanding the number of cribs is deferred.
2. Review life-safety
compliance, immediate repair requirements and space needs for current programs;
and then develop a facilities improvement/ expansion plan for the current HC
site.
D. Disaster Management
1. Prepare and stock
an “Emergency Medical Kit”.
2. Create a “pick up
and go” medical information file for each infant in residence, and personnel
file for each staff member.
3. Design, implement and monitor compliance of a flu
prevention protocol (e.g., babies, staff, Board members, visitors, volunteers))
4. Develop emergency
plans for various possible major incidents: chemical, natural, terrorist,
bioterrorist, radiological.
5. Prepare criteria
and plans for “Shelter in Place” and various evacuation options.
6. At least quarterly
prepare copy computerized financial data for off-site storage; also scan, for
off-site storage, critical documents such as tax-exempt letters, group home
license etc.
E. Development/ Marketing
1. Complete historical profile of HC fund-raising
accomplishments (as well as previous donors who no longer contribute).
2. Set goal for fund-raising share of HC annual budget.
3. Establish permanent Development Committee in the By-Laws,
then
4. Prepare and Annual Development Plan.
5. Prepare job description for a HC Development position
including rationale for its being full time or part (and how it will be
funded).
F. Board of Trustees
1. The Board should adopt a “Statement of Board Member
Responsibilities.”
2. The Nominating Committee should prepare matrix of
expertise and term limit dates of current Board members (and additional
expertise the Board needs), then,
3. Recruit new qualified potential candidates for Board
membership until the matrix is filled.
4. The Chairman and the CEO should develop an Orientation
program for new Board members.
5 The Executive Committee should prepare templates for
Annual Board Evaluation and individual Board member self-evaluation.
6. At least once a year the Board should discuss a Board
Leadership Succession Plan.
G. CEO
1. The Board should approve a current CEO job description
(including educational, clinical and experience requirements for any future
CEO).
2. A format for the
CEO’s Annual Evaluation should be prepared by the Chairman and approved by the
Board.
3. At least once a year the Board should review a CEO succession plan.
On March 26, 2017 I posted an obituary on REPEAL & REPLACE
after House Speaker Paul Ryan said his
party “came up short” in a news conference minutes after pulling the GOP
healthcare bill off the House floor, acknowledging that ObamaCare will stay in
place “for the foreseeable future.””
Yet on December 20th, 2017 the INDIVIDUAL MANDARE was
repealed. ““When the individual mandate is being repealed that means ObamaCare
is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we
will come up with something much better…” (WRECK & REJOICE)
During the ten months between REPEAL & REPLACE and WRECK
& REJOICE I posted over seventy updates. You can find links to this
chronology further down on this post.
Now there is an opportunity to track four ongoing and
competing health care strategies.
Medicare for All
Court challenges of the Affordable Care Act
The new Democrats plan
The next Republican plan
__________
What was once seen as a long-shot pitch from Vermont independent Sen. Bernie Sanders during his 2016 presidential campaign is now a proposal that at least four of his Senate colleagues also vying for the party’s 2020 nomination supported during the last Congress. The issue is driving the national political health care debate…
Democrats are already contending with industry groups hoping
to shift the focus back to strengthening the current system. Most drug
companies, hospitals and insurers oppose Medicare for All, which undoubtedly
complicates progressives’ efforts. The party’s left wing is pushing a bold,
pricey plan carrying political risks that make Democratic leaders shudder.
Despite all the inevitable political hurdles, getting a single-payer law
enacted may look easy compared to implementing it…
A single-payer health care plan would significantly change
every sector of the health care industry. Hospitals and doctors would need to
adjust to a new payment system, the insurance industry would shrink to a
fraction of its size, and the government would bring drug companies to the
negotiating table to determine prices.
The 2010 health care law left in place most of the existing
health care infrastructure in the U.S. Still, experts warn that the lessons
from that more incremental transition show how dramatic it would be to shift to
a single-payer system.
Supporters aren’t intimidated by the seismic nature of the
change. The hope is not just to ensure that everyone has coverage, but also to
take on health care companies seeking to maximize their profits, said Adam
Green, a co-founder of the Progressive Change Campaign Committee, a political
action committee that supports liberal candidates.
“Medicare for All boils down to two things,” Green said.
“One is universal coverage. The other is corporate accountability.” (A)
“Here’s where the Democratic candidates stand on Medicare
for All:
Sen. Elizabeth Warren (Mass.)
Warren co-sponsored Sanders’s Medicare for All proposal in
2017. But she has said that the broader goal is “affordable health care for
every American,” and that there are “different ways” to achieve that objective.
She has previously backed legislation that would allow
people to buy into a Medicaid-based public option on state insurance markets.
Sen. Cory Booker (N.J.)
Booker co-sponsored Sanders’s Medicare for All legislation.
But he has also rejected that private health insurance be eliminated under such
a health care system and has also expressed support for a more incremental
approach in which Medicare eligibility is expanded.
Booker has also signed on to legislation that would lower
the Medicare eligibility age to 50, as well as a proposal to allow people to
buy into a Medicaid option through state insurance marketplaces.
Sen. Kamala Harris (Calif.)
Harris is among a handful of 2020 Democrats who signed on to
Sanders’s Medicare for All bill and has said that she would support eliminating
private health insurance altogether.
Harris has also co-sponsored proposals that would lower the
age of Medicare eligibility to 50 and create a Medicaid option on state
insurance markets that people currently ineligible for the program could buy
into.
Sen. Bernie Sanders (I-Vt.)
Sanders has long been the most vocal advocate in the Senate
for a Medicare for All system and helped popularize the concept during his
insurgent bid for the White House in 2016.
He said in an interview on MSNBC on Tuesday night that he
would not support any Democratic legislation on health care other than his own
Medicare for All proposal. Sanders also reiterated his past assertion that
lawmakers should “get rid of” private insurance under such a plan.
Sen. Kirsten Gillibrand (N.Y.)
Gillibrand supports a Medicare for All proposal and
co-sponsored Sanders’s 2017 legislation seeking to implement such a plan.
She’s also signed on to measures lowering the age of
eligibility for Medicare to 50 and creating a public health care option through
Medicaid on individual state insurance marketplaces.
Former Rep. Beto O’Rourke (Texas)
O’Rourke has said he backs “universal health care.” But
unlike some of his more progressive challengers, he’s thrown his support behind
a different kind of proposal, dubbed Medicare for America, that would allow
Americans to join a public Medicare-based plan, while preserving the option to
remain on employer-based insurance.
“It responds to the fact that so many Americans have said,
‘I like my employer-based insurance. I want to keep it. I like the network I’m
in. I like the doctor that I see,’ ” O’Rourke told The Texas Tribune earlier
this month.
Sen. Amy Klobuchar (Minn.)
The Minnesota senator has refused to explicitly support
Medicare for All, offering up a more incremental approach to health care reform
that would involve creating a public, Medicaid-like option.
On Medicare for All, Klobuchar has said that it is
“something we can look to for the future,” but that she wants “action now” — a
nod to the likely challenges such a sweeping proposal would face.
(Also: Washington Gov. Jay Inslee; Former Colorado Gov. John
Hickenlooper; Rep. Tulsi Gabbard (Hawaii);South Bend, Ind., Mayor Pete
Buttigieg; Former San Antonio Mayor Julián Castro; Andrew Yang; Marianne
Williamson; Former Rep. John Delaney (Md.) (B)
“CMS Administrator Seema Verma wrote in an op-ed for The
Wall Street Journal that “Medicare for All” proposals would harm
seniors’ access to care by bringing all Americans into a system created to
support just older adults…
“The monetary cost of Medicare for All is surpassed by
its moral cost,” she writes. “The plan would strip coverage from more
than 180 million Americans and force them into government insurance. It will
resemble the Veterans Administration, which has been plagued by unreasonable
wait times, poor customer service, provider shortages and little accountability
in the administration of care.”” (C)
“The Trump administration is siding with Obamacare opponents
who argue that it is unconstitutional and should be scrapped entirely,
initiating a new, more aggressive assault on the health care law that will
assure the issue will be squarely at the forefront of the 2020 presidential
campaign.
The Justice Department shifted its stance, after arguing
last year that some parts of the 2010 law — but not all of it — should be
struck down in a case brought by the state of Texas. A federal district judge voided
the law in a December ruling that is now under appeal.
In a filing late Monday night, the Justice Department said
that President Barack Obama’s signature legislative achievement should be wiped
out.
“The Department of Justice has determined that the district
court’s comprehensive opinion came to the correct conclusion and will support
it on appeal,” DOJ spokeswoman Kerri Kupec said in a statement.
The filing draws renewed attention to Trump’s and the Republican
Party’s stance that Obamacare, formally known as the Affordable Care Act,
should be eliminated. That would include subsidies for coverage and rules
popular with voters such as preventing insurers from discriminating against
those with pre-existing conditions, limits on coverage and coverage for
preventative care.” (D)
“The Affordable Care Act was already in peril after a
federal judge in Texas invalidated the entire law late last year. But the
stakes ramped up again this week, when President Trump’s Justice Department
announced it had changed its position and agreed with the judge that the entire
law, not just three pieces of it, should be scrapped.
A coalition of states is appealing the ruling. If it is
upheld, tens of millions more people would be affected than those who already
rely on the nine-year-old law for health insurance. Also known as Obamacare,
the law touches the lives of most Americans, from nursing mothers to people
eating at chain restaurants.
Here are some potential consequences, based on estimates by
various groups.
Of the 23 million people who either buy health insurance
through the marketplaces set up by the law (11.4 million) or receive coverage
through the expansion of Medicaid (12 million), about 21 million are most at
risk if Obamacare is struck down. That includes 9.2 million who receive federal
subsidies.
On average, the subsidies covered $525 of a $612 monthly
premium for customers in the 39 states that use the federal marketplace,
HealthCare.gov, according to a new report from the Department of Health and
Human Services. If the marketplaces and subsidies go away, a comprehensive
health plan would become unaffordable for most of those people and many of them
would become uninsured.
States could not possibly replace the full amount of federal
subsidies with state funds.
Medicaid, the government insurance program for the poor that
is jointly funded by the federal government and the states, has been the
workhorse of Obamacare. If the health law were struck down, more than 12 million
low-income adults who have gained Medicaid coverage through the law’s expansion
of the program could lose it.
In all, according to the Urban Institute, enrollment in the
program would drop by more than 15 million, including roughly three million
children who got Medicaid or the Children’s Health Insurance Program when their
parents signed up for coverage…
As many as 133 million Americans — roughly half the
population under the age of 65 — have pre-existing medical conditions that
could disqualify them from buying a health insurance policy or cause them to
pay significantly higher premiums if the health law were overturned, according
to a government analysis done in 2017. An existing medical condition includes
such common ailments as high blood pressure or asthma, any of which could
require someone buying insurance on their own to pay much more for a policy, if
they could get one at all…
The 156 million Americans who get coverage through an
employer, as well as the roughly 15 million enrolled in Obamacare and other
plans in the individual insurance market, are protected from caps that insurers
and employers used to limit how much they had to pay out in coverage each year
or over a lifetime. Before the A.C.A., people with conditions like cancer or
hemophilia that were very expensive to treat often faced enormous out-of-pocket
costs once their medical bills reached these caps.
While not all health coverage was capped, most companies had
some sort of limit in place in 2009. A 2017 Brookings analysis estimated that
109 million people would face lifetime limits on their coverage without the
health law, with some companies saying they would cover no more than $1 million
in medical bills per employee. The vast majority of people never hit those
limits, but some who did were forced into bankruptcy or went without treatment…”
(E)
““President Donald Trump declared that the GOP will now be
the “party of health care.” The problem? His party doesn’t have a health care
plan. Congressional Republicans, who failed to repeal and replace Obamacare
when they controlled both chambers, were completely blindsided this week by the
Trump administration’s surprising decision to back a court ruling that would
throw out the entire Affordable Care Act, including the popular protections for
people with pre-existing conditions.
The move baffled many in the GOP, who believe the issue cost
them the House in the last election. And Axios first reported that House
Minority Leader Kevin McCarthy (R-Calif.), a Trump ally, even voiced his concerns
over the administration’s decision directly with the president. Republicans
from across the spectrum would prefer to focus on more narrow health care
issues that are an easier lift, like lowering prescription drug prices.” (F)
“House Democrats are rolling out a plan to strengthen the
Affordable Care Act that would expand federal insurance subsidies and reverse
the Trump administration’s attacks on the health care law — but avoids the
party’s internal fight about more ambitious proposals to extend health coverage…
The Democratic bill is a smorgasbord of provisions to expand
health care and undo the Trump administration’s regulatory actions to weaken
the ACA:
It expands the tax credits available under the law, both
reducing costs for lower-income families and expanding eligibility so
middle-class Americans can receive federal assistance.
It creates a national reinsurance program to offset high
medical bills for insurers and thereby keep premium increases in check.
It rolls back Trump actions expanding skimpier health
insurance plans, giving states the freedom to undermine the law’s benefits
requirements, and cutting enrollment outreach funding…
The rest of the bill is a string of more technical
provisions: creating a national reinsurance program, fixing the so-called
“family glitch” that barred some families from accessing tax subsidies, and,
importantly, reversing the Trump administration’s regulatory agenda. The
Democratic bill rolls back or otherwise curtails Trump’s expansion of
short-term insurance plans not required to meet the ACA’s protections for
preexisting conditions. It also requires the administration to spend federal
money on enrollment outreach, after Trump officials cut that budget
dramatically over the past two years…
Notably missing from the Democratic bill is a public option
or Medicare buy-in, the introduction of a government health care plan to
compete with the private insurance offerings of the ACA’s marketplaces…
House Speaker Nancy Pelosi has sounded skeptical notes about
single-payer and urged Democrats to focus on strengthening Obamacare, their
winning message in the midterms, so this new bill doesn’t come as a surprise.
Leadership is taking a more deliberate approach to their party’s more ambitious
health care ideas, where there is not yet a consensus within the ideologically
diverse Democratic majority.” (G)
““Mitch McConnell has no intention of leading President
Donald Trump’s campaign to transform the GOP into the “party of health care.”
“I look forward to seeing what the president is proposing
and what he can work out with the speaker,” McConnell said in a brief interview
Thursday, adding, “I am focusing on stopping the ‘Democrats’ Medicare for none’
scheme.”
The Senate majority leader spent untold weeks and months on
the party’s health care quagmire in 2017, when the GOP controlled both the
House and the Senate and still failed to repeal Obamacare. The episode caused
endless headaches for Republicans as their replacement plan fell apart first,
followed by the so-called “skinny” plan they slapped together at the last
minute.
Now in divided government, with the Senate majority up for
grabs next year and McConnell himself running for reelection, another divisive
debate over health care is the last thing McConnell needs. But that’s exactly
where Trump is taking Republicans after his administration endorsed a wholesale
obliteration of the law in the courts earlier this week.
So the Kentucky Republican and his members are putting the
onus on the president to figure out the next steps.
McConnell’s clear reluctance toward trying to draft a
sweeping health care bill in the Senate reflects his political instincts: that
it’s better to focus on perceived Democratic weaknesses — the left’s push on
“Medicare for All” — than to struggle to unify his own party on a plan almost
certain to be rebuffed by Senate Democrats and House Speaker Nancy Pelosi
(D-Calif.). “ (H)
“The White House is quietly working on a healthcare policy
proposal to replace the Affordable Care Act, according to multiple sources with
knowledge of the matter.
While it is not clear how far along the process is, work on
a proposal has been going on for months. The effort appears to belie criticism
that Trump’s decision to restart the debate on healthcare, an issue Democrats used
to their advantage in the 2018 midterms, was an error committed without
forethought.
“The White House, mainly through the National Economic
Council, has been engaged on thinking about health care reform for a while now,
and they have been engaged with a group of center-right health policy groups to
talk about various proposals and ideas,” a conservative health policy analyst
told the Washington Examiner.
The analyst said the administration has been “having
conversations” on healthcare policy and has reached out to numerous think
tanks, including the Heritage Foundation, the Mercatus Center, and the Hoover
Institute…
Policy leaders at several conservative think tanks confirmed
to the Examiner that a healthcare plan is indeed the works. They said a proposal
would take concepts from the Graham-Cassidy bill, by Sen. Lindsey Graham,
R-S.C. and Sen. Bill Cassidy, R-La., and the Health Care Choices proposal,
which was signed by many conservative policy leaders, including the Heritage
Foundation and former Sen. Rick Santorum, R-Penn. One analyst said a White
House proposal would most likely be brought up in the Senate first.
Heritage Foundation Director of Domestic Policy Studies
Marie Fishpaw noted that the president has already included concepts from the
Health Care Choices proposal in his 2020 budget.
The proposal, according to Fishpaw, “would lower premiums by
up to a third, lowering costs while also protecting people with pre-existing
conditions.” It would replace federal payments to insurance companies with grants
for each state, giving individual states more leeway to determine how to use
the money.
One conservative policy analyst said that although the White
House is definitely “exploring” the healthcare issue, it does not seem ready to
unveil a proposal…
Trump has already asked a group of Senate Republicans,
including John Barrasso of Wyoming, Rick Scott of Florida and Cassidy to come
up with a replacement for Obamacare. But other Senate Republicans, including
Sens. Roy Blunt of Missouri, John Kennedy of Louisiana and Majority Leader
Mitch McConnell, have indicated an unwillingness to get moving on the issue
until Trump puts forth his own proposal.
“I’m anxious to see what the White House is going to
recommend in terms of a healthcare delivery system that looks like somebody
designed the damn thing on purpose,” Kennedy said.” (I)
“President Donald Trump on Monday night backed away from his
push for a vote on an Obamacare replacement until after the 2020 elections,
bowing to the political reality that major health care legislation cannot pass
in the current Congress.
Trump’s statements come a week after his administration
announced that it now agreed with a judge’s ruling that the entire Affordable
Care Act should be scrapped. The opinion was a dramatic reversal from the
administration’s previous stance that only portions of the act could not be
defended.
Trump’s latest move allows him to wait on the issue as legal
challenges against the health care law, also known as Obamacare, make their way
through the federal court system. If it’s ultimately overturned, Trump can
claim he made good on a campaign promise in time for his 2020 re-election
campaign — though he would then face the prospect of an estimated 20 million
Americans losing their health insurance on his watch, with no Republican
replacement in the legislative pipeline. If it’s upheld — as it has been in
previous Supreme Court challenges — he can rail against a “liberal”
court system…
Trump unsettled Republican lawmakers last week by putting
the spotlight back on the thorny issue of repealing and replacing Obamacare,
vowing that his party would turn to replacing the health care law as his
administration backed a federal court ruling striking down the law in its
entirety. Republican congressional leaders quickly sought to distance
themselves from Trump’s latest drive, mindful that passing such a proposal
would be virtually impossible in a divided Congress…
Trump said Thursday he’s asked Republican senators to work
on a replacement to the Affordable Care Act, but no such group appears to
exist. Multiple Republican senators who Trump name-checked said they were not a
part of a working group, but had spoken with the President about health care
recently.
And on Wednesday, Marc Short, Vice President Mike Pence’s
chief of staff and the former White House legislative affairs director, claimed
on CNN that “the President will be putting forward plans this year”
to replace Obamacare through Congress.
White House officials were quick to tell CNN that Short had
gotten ahead of White House deliberations.
The White House has yet to decide whether it will take the
lead on crafting an Obamacare replacement, they said, or whether the President
will punt to Republican lawmakers.” (J)
Cruz health care bill amendment – “….healthy people could
get coverage although that coverage might not protect them if they got sick and
sick people would have to pay an unaffordable amount for coverage.”
What would Albert Einstein have said about TrumpCare? “The
definition of insanity is doing something over and over again and expecting a
different result.”
Republican Talking Points on the new Senate Health Care
Bill. Democratic Party response – “Senate Republicans spent the past two weeks
putting lipstick on a pig”
Last week Senator McCain said the “Senate healthcare deal
could be reached by Friday ‘if pigs fly’” (A). Now he has a deciding vote on
the Republican “junk insurance” bill!
“Laws are like sausages, it is better not to see them being
made.” (Otto von Bismarck). Or not made…two conservative Republican Senators
kill TrumpCare….for now
“The vote is a reward to the ultras who sabotaged repeal and
replace by allowing them to posture one more time as purists who have not
forsaken the true faith.”
“McConnell is still planning votes on health-care
legislation next week. But many things have to go right for his strategy to
succeed, and not all of them are within his control.”
“….. the parliamentarian has taken an already very difficult
process for enacting health care legislation in the Senate and made it nearly
impossible….”
Rep. Blake Farenthold (R-Texas) suggested….that he’d like to
duel with female senators he blames for the Senate’s failure to repeal and
replace ObamaCare
The House and Senate played “dodgeball” not wanting to be
held accountable when twenty million people, their constituents, would lose
access to affordable care.
“.. here’s the first thing I thought about: feel better,
Hillary Clinton could be president..” (Senator McConnell) (A) “McCain Voted
Against Health Care Bill…Because it Would ‘Screw’ Arizona.” (B)
“In politics you can tell your friends from your enemies,
your friends are the ones who stab you in the front”.* Look at what the
Republicans are saying about each other now about health care
For 17 years I was President and CEO of a safety net
hospital. TrumpCare will “disinsure” twenty million+ people and devastate the
hospitals we all depend on.
President Trump tweeted he ”.. would not sign Graham-Cassidy
if it did not include coverage of pre-existing conditions. It does! A great
Bill. Repeal & Replace.” IT DOESN’T!
TrumpGrahamCassidy. “Perhaps one of the biggest challenges
for the bill will come next week when the Senate parliamentarian — an umpire of
sorts for the chamber’s rules — takes a look at the bill…”
White House Director of Legislative Affairs Marc Short is
defending the proposed Graham-Cassidy bill — – by countering criticism that the
bill does not provide coverage for those with pre-existing conditions.
“I personally think it’s time for the American people to see
what the Democrats have done to them on health care,” said Senate Finance
Committee Chairman Orrin G. Hatch (R-Utah).
Last minute Sunday night Graham Cassidy revisions included..
a pretty sweet deal for the state of Lo uisiana, home of one of the bill’s
sponsors Sen. Bill Cassidy.
On March 24th, 2017. “Speaker Paul Ryan (R-Wis.) on Friday
said his party “came up short” in a news conference minutes after pulling the
GOP healthcare bill off the House floor, acknowledging that ObamaCare will stay
in place “for the foreseeable future.””
Yet on December 20th, 2017 the INDIVIDUAL MANDARE was
repealed. ““When the individual mandate is being repealed that means ObamaCare
is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we
will come up with something much better…”
“Andy Slavitt, who served as the acting administrator for
the Center for Medicare and Medicaid Services under President Barack Obama,
warned late Friday night that Republicans may try to repeal and replace
Obamacare once again before the 2018 midterm elections. “Republicans have been
meeting in secret to bring back ACA repeal,” he writes…
… Santorum and others may think that there will be a “blue
wave” in 2018 no matter what, so this may be the last time the GOP has the
opportunity to get rid of Obamacare. And that might make Republicans desperate
enough to try again.” (R)
At the end of this post there are links to a series of over
60 posts tracking the activity between March 24th and December 20th. Laws are
like sausages,” goes the famous quote often attributed to the Prussian
Chancellor Otto von Bismarck, “it is better not to see them being made.”
In 2018, mostly under-the-radar, efforts are continuously
underway to continue to undermine what’s left of ObamaCare.
“Republicans, having failed to repeal Obamacare, have
stumbled, almost accidentally, into replacing it. For better and for worse, and
with little coherent vision at work, they are making Obamacare their own. And
over time, they are likely to embrace it…,
Congress has already repealed several unpopular parts of the
law as part of last year’s tax legislation — most notably the individual
mandate, which now expires at the end of this year, but also the Medicare
cost-control board (known as the Independent Payment Advisor Board).
The executive branch has exerted its own influence on the
law. In October of last year, President Trump signed an executive order calling
for the expansion of association health plans and limited-duration insurance,
in hopes of creating a secondary market for health plans that are cheaper and
less regulated, and this year, the administration released extensive proposals
for each. The administration also stopped paying the law’s cost-sharing
reduction subsidies, which reimburse insurers for low-income beneficiaries. And
the Department of Health and Human Services has begun allowing states to attach
work requirements to Medicaid, making the program more bureaucratic, but
possibly enticing red states that have so far declined to expand the program to
do so…
Having failed in their repeal effort, Republicans are now in
something of an arranged marriage with the health care law. These alterations
are being made in a predictably haphazard fashion, with little in the way of
guiding theory, but the cumulative effect is to turn Obamacare into a law that
they can, if not love, at least learn to live with.”(A)
“Bigger changes are coming. The administration has proposed
regulations that would allow so-called short-term health plans to be offered
for nearly a year of coverage. Those plans aren’t subject to any Obamacare
rules in most states, and are likely to be marketed aggressively. They are
likely to cover fewer health services and be available only to the healthy —
but at a lower price. Another pending rule would expand the availability of
association health plans, a form of group insurance purchasing that may be
attractive to small businesses looking for cheaper, less comprehensive
options….
People buying those plans may face some unpleasant
surprises. The plans are likely to require applicants to fill out detailed
health histories, and to exclude those with prior illnesses. They also are
likely to exclude or limit services — like addiction treatment, maternity care
or prescription drugs — that all Obamacare plans require. Association plan
buyers have tended to have problems with fraud. And some short-term plans have
a history of declining to pay for serious illnesses after the fact.
But even if the new plans serve their customers well, their
popularity could leave the remaining markets a bit shakier. Because the
short-term plans will be open only to the healthy, the remaining customers will
tend to be sicker, and more expensive to insure.” (B)
“It’s been well documented that the Trump White House has
filled federal agencies with bureaucrats whose life work is destroying the very
agencies they’ve been assigned to. But one is in a better position than her
fellows to threaten the health of millions of Americans—and she’s been working
at that assiduously.
We’re talking about Seema Verma, who as administrator of the
Centers for Medicare and Medicaid Services also is effectively the
administrator of the Affordable Care Act. In the Trump administration, that has
made her the point person for the Trump campaign to dismantle the act,
preferably behind the scenes…
Still, Verma had spent enough time in the healthcare field
that observers thought she might not be totally egregious as CMS administrator.
But then, during her confirmation hearing in February 2017, she let on that she
didn’t see why maternity coverage really needed to be mandated for all health
policies, since “some women might want maternity coverage, and some women might
not want it…
It wasn’t an auspicious start. But since then she has lived
down to our expectations. Verma never has concealed her hostility to Medicaid —
especially Medicaid expansion, a provision of the ACA. Her animosity is fueled
at least in part by ignorance (willful or otherwise) about the program. Back in
November, on the very day that voters in Maine and Virginia were demonstrating
full-throated support at the polls for expanding Medicaid in their states,
Verma was unspooling a string of misleading statistics and suspect assertions
about the program to support a policy of rolling back enrollment.” (C)
“Passing two measures aimed at stabilizing the Affordable
Care Act marketplaces by infusing insurers with more funds would lower monthly
premiums by 20 to 40 percent and prompt an additional 3.2 million people to get
covered, says an attention-grabbing independent analysis released yesterday by
the firm Oliver Wyman.
These measures – which would pay insurers for extra
cost-sharing discounts for the low-income and reimburse them for their most
expensive customers – are currently stuck in political limbo as leaders on
Capitol Hill consider whether to include them in a massive, must-pass spending
bill next week.
The bills have become emblematic of inter and intraparty
disputes over how to approach a world with most of the ACA still in place.
Democrats are bitter that Republicans are still chipping away at parts of the
law by repealing its individual mandate and changing other provisions through
the executive branch…
And Republicans can’t even agree among themselves how to
handle the law now that they’ve failed to entirely wipe it from the books. (D)
“Republicans campaigned for roughly a decade, promising
voters they would dismantle former President Barack Obama’s landmark health
care legislation; but one of their own senators is trying to keep it alive
through the 2018 election cycle…
Sen. Lamar Alexander, R-Tenn., along with Sen. Patty Murray,
D-Wash., is using the deadline to sway leadership to include a proposal that
would fund politically contentious Obamacare subsidies through 2019. The
proposal would provide $10 billion a year for three years for these subsidies…
Additionally, the proposal would give states greater
Obamacare waiver flexibility and would broaden consumer eligibility for “copper”
plans. Abortion-covering health insurance plans would not receive subsidies
under the proposal…
Republicans are either not thrilled about Alexander’s
proposal, calling it a bad idea and one that could hurt the party going into
2018, or they think it could be one way to provide taxpayers some relief from
the financial burdens Obamacare imposed.” (E)
“The House passed the $1.3-trillion omnibus spending package
meant to keep the government running until Sept. 30 in a vote of 256-167,
leaving the Senate barely 35 hours to get the same legislation approved by
Friday at midnight to avert a shutdown.
The bill boosts funding for the National Institutes of
Health, the CDC, and the Department of Veterans Affairs (VA) as well as other
key agencies, but keeps funding flat for the Centers for Medicare and Medicaid
Services…
The bill also does not include the health insurance
stabilization bill from Sen. Lamar Alexander (R-Tenn.) and Sen. Susan Collins
(R-Maine). They had wanted the omnibus package to include measures restoring
for 3 years the cost-sharing reduction subsidies (monies that help insurers
defray out-of-pocket costs for low-income enrollees), establishing 3 years of
reinsurance (monies that help pay for the sickest of patients and keep premiums
from spiking) at $10 billion per year, and streamlining the 1332 waiver process
to allow states more flexibility in health plan design.” (F)
“The Trump administration hopes to move forward with a rule
expanding alternatives to ObamaCare plans by this summer, Secretary of Labor
Alex Acosta said Monday. The rule allows small businesses and self-employed
individuals to band together to buy insurance as a group in what are known as
association health plans. “We hope to have that by this summer,” Acosta said
Monday during a tax reform event alongside President Trump in Florida.” (G)
“In 2012, the Supreme Court of the United States upheld
Obamacare in a 5-4 ruling, with Chief Justice John Roberts writing the majority
opinion. Many Obamacare opponents believe Roberts used contorted reasoning to
save the law by labeling Obamacare’s individual mandate penalty a tax.
Now, six years later, 20 states have seized on the Roberts
ruling to ask the courts again to undo Obamacare. These states filed a lawsuit
indicating that because the December 2017 tax reform bill repealed the
individual mandate penalty, there’s no longer any legal rationale for the
mandate. They also argue that because there’s no “severability clause” in
Obamacare, the entire law must be struck down.
If this sounds confusing, read on to unpack what’s going on
with this latest attempt to undo Obamacare through the courts.
The Obamacare mandate was ruled a tax…
Opponents of the law argued Congress didn’t have the power
to require individuals to purchase a product from private insurers, while the
Obama administration argued authority for the mandate came from the Commerce
Clause, which gives the federal government power to regulate commerce “among
the several states.”” (H)
“Gov. Scott Walker has asked for a federal waiver to operate
a state-based reinsurance plan designed to stabilize the state’s individual
health insurance market and hold down premiums under the Affordable Care Act.
Following a 44 percent average spike in Obamacare premiums
this year, Walker’s office estimates the $200 million program would lower
premiums by 11 percent from what they otherwise would have been, amounting to a
5 percent decrease in premiums compared to 2018.
Under the plan, the state would pay $34 million for
reinsurance in 2019, while $166 million would come from federal funds…
“We are taking action to address the challenges created by
Obamacare and bring stability to the individual market,” Walker said. “Our
Health Care Stability Plan provides a Wisconsin-based solution to help
stabilize rising premiums in order to make health care more affordable for
those purchasing in the individual market. With Washington D.C. failing to fix
our nation’s health care system, Wisconsin must lead.” (I)
“The American Academy of Family Physicians and other doctor
groups have unleashed detailed critiques of Trump’s effort to introduce cheaper
health insurance with skimpier benefits….
“Insurers could reduce or eliminate certain essential health
benefits to avoid vulnerable, expensive patients by excluding specific
services,” AAFP board chair Dr. John Meigs, Jr., a family physician from
Alabama wrote in a letter last week to U.S. Health and Human Services Secretary
Alex Azar.
“In doing so, insurers could potentially make plans more
expensive for people with long-term chronic conditions or with sudden medical
emergencies,” Meigs said. “Inadequate benefits could leave this population with
too little coverage to meet their health care needs.” (J)
“The Affordable Care Act (aka Obamacare) banned any
hospital, doctor, or insurance company who receives federal funding from
discriminating against or denying services based on sex; the Obama
administration made it clear in 2016 that provision included transgender and
gender-nonconforming patients…
These benefits and protections are heading for oblivion
though, according to the Times. The Trump administration is pointing to a
January 2017 ruling from a Texas federal judge who said the 2010 law did not
cover gender identity or presentation.
“Congress did not understand ‘sex’ to include ‘gender
identity,’” Judge Reed O’Connor ruled. In the Affordable Care Act, he said,
Congress “adopted the binary definition of sex.” (K)
“As Republicans careen toward the midterms with tax reform
under their belts and not much else, rumor has it that a small group of
Republican senators are working with the White House and former Sen. Rick
Santorum (R-Pa.) to revive the debate over ObamaCare repeal.
Their purpose is laudable. But, privately, conservatives
across Capitol Hill are expressing concern that the proposal may not do enough
to dismantle ObamaCare’s regulatory structure, reduce its colossal spending, or
allow freedom to innovate outside the law’s stifling framework…
The bill’s premise — to devolve much of the health-care
spending to the states — is a good starting point. But its implementing details
are still unknown, leaving conservatives to wonder if the new bill will
actually repeal ObamaCare and reform the health-care marketplace, or if it will
simply recast much of the law’s worst elements with a few minor tweaks…
Voters are still waiting for a full repeal effort. Anything
less will not suffice as a solution for candidates who will soon be elected on
a message of repeal. Nor will it suffice for a party who has spent years making
the same promise.” (L)
“Less than a year after the GOP gave up on its legislative
effort to repeal the law, Democrats are going on offense on this issue,
attacking Republicans for their votes as they hope to retake the House
majority…
ObamaCare’s favorability in polls has improved since the
repeal push last year, with more now favoring the law than not. A Kaiser Family
Foundation poll in March found that 50 percent of the public favors the law,
while 43 percent holds an unfavorable view.
GOP strategist Ford O’Connell said the political winds have
shifted on the issue, turning ObamaCare into a subject Democrats want to tout
and many Republicans want to duck.
“I don’t think it’s seen as a winning issue,” he said. “It’s
also an issue that tends to fire up the Democratic base more so than the
Republican base.”” (M)
“While Republican moves to overhaul Social Security,
Medicare or Medicaid appear unlikely — at least for this year — Democrats are
increasingly warning about the prospect because of the deficit concerns created
by the tax plan. The GOP argues Democrats want to distract from the fact that
they did not support the tax overhaul, the signature Republican achievement of
Trump’s first year in office.
Democrats’ ability to sell voters on their vision for health
care and warn about the possibility of cuts to Social Security and Medicare
could prove crucial for candidates, such as Manchin, who are trying to win in
red areas…
Polling suggests Trump and the GOP’s efforts to reshape the
American health-care system have not resonated with voters. Thirty-six percent
of respondents to the Economist/YouGov poll said they strongly disapprove of
how the president has handled health care, compared with only 15 percent who
said they strongly approve.” (N)
“People have voted with their enrollment decisions: A
sizable number of Americans do not get insurance from their employers and value
the coverage on Obamacare’s markets. That refutes the GOP myth that the program
forces Americans to purchase junk insurance that they do not want. A recent
Kaiser Family Foundation poll found that these consumers seek to guard against
major medical costs, to gain the peace of mind that comes with insurance and to
obtain coverage for chronic medical care, suggesting that the law serves
important and durable needs.
Another fictional Republican claim is that Obamacare has
been collapsing. A Kaiser study this year found that insurance markets
stabilized in 2017, despite Mr. Trump’s best efforts to undermine the law. This
comports with findings from the Congressional Budget Office and a range of
other independent analysts…
Obamacare continues to serve an important need. What’s sad
to see is how easy it would be to make it even more useful, if Republicans
would focus on improvement instead of sabotage.” (O)
“What’s the secret of Obamacare’s stability? The answer,
although nobody will believe it, is that the people who designed the program
were extremely smart. Political reality forced them to build a Rube Goldberg
device, a complex scheme to achieve basically simple goals; every progressive
health expert I know would have been happy to extend Medicare to everyone, but
that just wasn’t going to happen. But they did manage to create a system that’s
pretty robust to shocks, including the shock of a White House that wants to
destroy it…
What this says to me is that if Republicans manage to hold
on to Congress, they will make another all-out push to destroy the act —
because they’ll know that it’s probably their last chance. Indeed, if they
don’t kill Obamacare soon, the next step will probably be an enhanced program
that lets Americans of all ages buy into Medicare.” (P)
“At the outset, Obamacare had three central features:
• Insurers could not charge higher prices to people with
pre-existing conditions.
• Those without coverage had to pay a penalty to the
government (the “mandate”).
• Low-income people would be eligible for subsidies.
The first two provisions were necessary to prevent the death
spiral, and government couldn’t mandate insurance purchases without adding
subsidies for the poor.
Despite a bumpy rollout and some frustrations over shrinking
choices and rising prices at health care exchanges, Obamacare was working
remarkably well by most important metrics. Program costs were much lower than
expected, and the uninsured rate among nonelderly Americans fell sharply — from
18.2 percent in 2010 to only 10.3 percent in 2018.
This progress is now imperiled.
The mandate — by far the program’s least popular provision —
was repealed as part of tax legislation passed in December 2017. And because
economists predict that its absence will slowly rekindle the insurance death
spiral, we’re forced back to the policy drawing board… (Q)
SEE OBAMACARE/ TRUMPCARE CHRONOLOGY AFTER THE FOOTNOTES
(A) The G.O.P. Accidentally Replaced Obamacare Without
Repealing It, by Peter Suderman
https://www.nytimes.com/2018/03/12/opinion/republicans-obamacare-health-care.html
(B) Republicans Couldn’t Knock Down Obamacare. So They’re
Finding Ways Around It., by Margot Sanger-Katz, https://www.nytimes.com/2018/04/11/upshot/republicans-couldnt-knock-down-obamacare-so-theyre-finding-ways-around-it.html
(C) How Trump’s Obamacare administrator is taking a hatchet
to Obamacare, by Michael Hiltzik,
http://www.latimes.com/business/hiltzik/la-fi-hiltzik-obamacare-verma-20180417-story.html
(D) The Health 202: Republicans could lower Obamacare
premiums. But will they?, by Paige Winfield Cunningham,
https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/03/13/the-health-202-republicans-could-lower-obamacare-premiums-but-will-they/5aa6a81330fb047655a06c0d/?utm_term=.923a4143e8d5
(E) Senate May Fund Obamacare Subsidies With This Sneaky
Move, by Robert Donachie,
https://www.dailysignal.com/2018/03/15/senate-is-going-to-fund-obamacare-subsidies-with-this-sneaky-move/
(F) House Passes Spending Bill Without Obamacare Fix, by
Shannon Firth
https://www.medpagetoday.com/publichealthpolicy/healthpolicy/71945
(G) Trump Official: Alternative to ObamaCare Plans Likely
This Summer, by Peter Sullivan, http://galen.org/2018/obamacare-watch-newsletter-4-20-18/
(H) States Take Another Run at Undoing Obamacare Through the
Courts, by Christy Bieber,
https://www.fool.com/investing/2018/04/22/states-take-another-run-at-undoing-obamacare-throu.aspx
(I) Amid rising Obamacare premiums, Walker seeks federal
waiver for reinsurance program, by op 5 percent, by Lauren Anderson,
https://www.biztimes.com/2018/ideas/government-politics/amid-rising-obamacare-premiums-walker-seeks-federal-waiver-for-reinsurance-program/
(J) Doctors Attack Trump’s Short-Term Health Plans Ahead Of
Comment Deadline, by Bruce Japsen,
https://www.forbes.com/sites/brucejapsen/2018/04/22/doctors-attack-trumps-short-term-health-plans-ahead-of-comment-deadline/#9049bad3fb10
(K) Trump to Allow Anti-Trans Discrimination in Health Care,
by BY NEAL BROVERMAN,
https://www.advocate.com/transgender/2018/4/22/trump-allow-anti-trans-discrimination-health-care
(L) Republicans have a long way to go toward fully repealing
ObamaCare, by Rachel Bovard, http://thehill.com/opinion/healthcare/383722-republicans-have-a-long-way-to-go-toward-fully-repealing-obamacare
(M) GOP in retreat on ObamaCare, by BY PETER SULLIVAN,
http://thehill.com/policy/healthcare/384032-gop-in-retreat-on-obamacare
(N) It’s not all about Trump: Democrats’ midterm chances
ride on health care and Social Security, too, by Jacob Pramuk,
https://www.cnbc.com/2018/04/16/not-just-trump-health-care-social-security-could-define-2018-midterm-elections.html
(O) Americans are sticking by Obamacare. If only the GOP
would stop trying to kill it.,
https://www.washingtonpost.com/opinions/americans-are-sticking-by-obamacare-if-only-the-gop-would-stop-trying-to-kill-it/2018/04/15/9b817832-3c2b-11e8-a7d1-e4efec6389f0_story.html?noredirect=on&utm_term=.e10e892994e9
(P) Obamacare’s Very Stable Genius, by Paul Krugman,
https://www.nytimes.com/2018/04/09/opinion/obamacare-trump.html
(Q) Back to the Health Policy Drawing Board, by ROBERT H.
FRANK,
https://www.nytimes.com/2018/03/16/business/back-to-the-health-policy-drawing-board.html
Assignment: Learn everything you can about sepsis than make sure your local hospital uses Artificial Intelligence to diagnose (and even recommend treatment for) sepsis?
Less than one day after burying his beloved wife Barbara, former President George H.W. Bush was hospitalized in the intensive care unit with sepsis.
He recovered and left the hospital, but too often this
potentially deadly condition takes lives.
In 2017 alone, 1 in 3 people who died in a hospital had sepsis.
The Centers for Disease Control tracks the disease and its
complications. Last year, it found at
least 1.7 million cases diagnosed in the United States.
What is sepsis?
Sepsis is the body’s extreme response to common bacterial
infections. Things as simple as an
infected skin cut, a urinary tract infection or illness affecting your lungs
can trigger it. If you don’t get proper medical attention quickly, it can lead
to tissue damage, organ failure and death.
It can strike anyone, but children, the elderly and those
with chronic health problems are most at risk.
To help you know your risk and to avoid putting yourself or
your family at risk, check out the CDC’s fact sheets on how to protect
yourself. (W)
“Do not take that slight cut on your knee or a bruise on
your elbow lightly for they can land your health in a complicated state called
sepsis. Sepsis occurs when an existing infection causes the immune system to
flare up intensely. As a result, your body swells up severely blocking the
blood flow to your organs. While the symptoms take 24 -48 hours to manifest, do
watch out for signs of fever, shortness of breath, unbearable pain, and a racy
heart. Although bacterial infections are said to be the major cause of the
disease, there are other culprits to watch out for.” (A)
Physicians will accept pathogen coverage of 80% to 90% from
their preferred empiric antibiotic regimen when managing patients with mild and
severe sepsis, respectively, from bacterial infections, survey results showed.
The survey of internal medicine physicians in Canada also
showed that physicians perceived that their preferred empiric antibiotic
regimen would cover 90% of the offending pathogens in each clinical scenario of
sepsis.
Researchers said the findings could be used to inform
clinical guidelines and improve prescribing practices.
According to Alex M. Cressman, MD, MSc, from the University
of Toronto and Sunnybrook Health Sciences Center, and colleagues, prescribers
must balance “early empiric antibiotic coverage and the antimicrobial
stewardship goal of minimizing unnecessary broad-spectrum treatment” when
choosing an antibiotic regimen. They suggested a need for treatment thresholds
to aid physicians in choosing empiric antibiotic regimens for patients with
serious bacterial infections.
“Using a
scenario-based survey of general internists and infectious disease specialists
across Canada, we characterized physicians’ perceived likelihood of adequate
coverage achieved by their preferred empiric antibiotic regimens for patients
with mild and severe sepsis,” Cressman and colleagues wrote. “We also
identified physicians’ minimum acceptable thresholds of adequate coverage for
these patients.”..
According to Kollef and Burnham, treatment bundles can
overlook important factors. Specifically, treatment bundles for sepsis tend not
to assess antibiotic necessity, dosing strategies and antibiotic duration, and
the in vitro activity of the antibiotic regimen. They highlighted the success
that rapid molecular diagnostics has had in expediting patient evaluation for
sepsis, ensuring effective, early antibiotic therapy and reducing the
unnecessary use of broad-spectrum agents.
“Further work is needed to understand their work in a
broader context that includes other front-line antibiotic prescribers,” Burnham
and Kollef wrote. “Empiric antibiotic prescribing will continue to be a moving
target, but with advances in [rapid molecular diagnostics], the ideal scenario
of minimizing antibiotic use while maximizing excellent patient outcomes moves
closer to realization, including in critically ill patients.” (B)
Hospitals have a hard time meeting the CMS’ sepsis treatment
requirements.
The national average compliance rate for the Severe Sepsis
and Septic Shock Early Management Bundle is barely 50%, according to the most
recent data on Hospital Compare. The measure was adopted in July 2015 to
improve hospitals’ identification and treatment of the life-threatening
condition. More than 200,000 people die each year from sepsis.
WellSpan Health, an integrated delivery system based in
York, Pa., has blown past that average, recently boasting an 85% compliance
rate for the bundle. WellSpan executives credit a year-old quality improvement
initiative that involves leveraging the electronic health record and a remote
patient monitoring team to identify and treat patients with sepsis early…
To address alert fatigue, WellSpan established a remote
surveillance team to monitor sepsis alerts and patients’ vital signs 24/7. The
Central Alert Team operates much like air traffic controllers do, with the
nurses monitoring patients at five hospitals, allowing them to review and
intervene when necessary.
“The idea of the alert team is to facilitate early recognition
and communication with the care team at the bedside, so they launch appropriate
interventions,” Delaveris said.
Alerts go to the Clinical Alert Team rather than nurses at
the bedside. Using patient record data on hand, nurses on the alert team will
determine if an alert should be elevated to the next level. If so, they contact
the patient’s physician or nurse directly to let them know the sepsis bundle
should be activated.
Because the nurses only reach out to the bedside team when
they see something amiss, the clinicians take their alerts seriously, Delaveris
said. WellSpan also introduced the nurses to the clinicians they’d be working
with so “it’s not just someone calling from the sky. We wanted to build a
relationship and trust,” he added.
At least one registered nurse with intensive-care and
emergency department experience is on duty at any given time monitoring
patients for sepsis.
The nurses also continuously monitor the patients they see
as at risk for sepsis to ensure the clinical team is following all of the
bundle’s steps. WellSpan opted to use the bundle from the Surviving Sepsis
Campaign, which is closely aligned with the CMS requirements. The bundle has
multiple steps that need to be accomplished within designated time periods.”
(C)
“Know the risks. Spot the signs. Act fast. Merit Health
Wesley has worked for the past few years to integrate evidence-based clinical
practices into the medical management of sepsis and reduce risk in the
community by educating the public about the illness.
Merit Health Wesley is the first in Mississippi to achieve
The Joint Commission’s Gold Seal of Approval for Sepsis Care.
“This achievement is a symbol of quality that reflects our
hospital’s ongoing commitment to providing safe and effective patient care,”
said Debbie Johnson, vice president of quality and clinical transformation and
patient safety officer. “We endeavor to provide the highest quality of sepsis
care through a comprehensive, multi-disciplinary approach to sepsis management
and long term recovery.”
The sepsis management team at Merit Health Wesley has
reduced the risk of sepsis by limiting the progression of sepsis. They are
focusing on early diagnosis and rapid, efficient and effective treatment. Key
elements of the hospital’s process are medical staff-approved sepsis protocols,
a team approach with focused patient handoffs, regular reviews of designed
process compliance, and accountability meetings to review outcomes. Merit
Health Wesley chose to authenticate their best practices and process
improvements by pursuing certification.
Since as many as 87 percent of sepsis cases start in the
community, Merit Health Wesley has also implemented a community outreach and
education plan. Patients and their families, nursing homes, emergency management
staff and other care providers are educated to increase their awareness of
sepsis and common early warning signs, as well as, evidenced based standards of
care for rapid treatment, all key to improved outcomes and survival.” (D)
“Massachusetts Institute of Technology researchers have
developed a machine-learning system that could help clinicians decide when to
treat patients for sepsis in the emergency room.
Sepsis is one of the most common reasons for readmission to
the hospital and one of the most common causes of death in the ICU. The
researchers suggest that most of the ICU patients are admitted through the
emergency room.
Treatment typically begins with antibiotics and IV fluids at
a couple liters at a time, according to the researchers. Sepsis shock can
happen if a patient’s body doesn’t respond well to treatment, which results in
blood pressure dropping dangerously low with organ failure. Once that happens,
the patient goes to ICU where clinicians can reduce and stop fluids to start
vasopressor medications to raise and maintain blood pressure.
However, giving a patient fluids for too long could cause
more organ damage. The researchers say that vasopressor intervention could be
helpful and has previously been linked to improved mortality in septic shock.
But administering vasopressors too early can cause heart arrhythmias and cell
damage, leaving clinicians with an unclear answer on when to administer
treatment.
MIT researchers have developed a model to alleviate that
problem. The model learns from health data on emergency-care sepsis patients
and can predict if a patient will need vasopressors within the next few hours.
In a study, the researchers compiled a dataset for ER sepsis
patients. When they tested the algorithm, the model was able to predict the
need for a vasopressor more than 80% of the time…
The machine-learning system could be used in a bedside
monitor to track patients and send alerts to clinicians in the ER about when to
start vasopressors and reduce fluids.
“This model would be a vigilance or surveillance system
working in the background,” Thomas Heldt, the study’s co-author, said. “There
are many cases of sepsis that [clinicians] clearly understand, or don’t need
any support with. The patients might be so sick at initial presentation that
the physicians know exactly what to do. But there’s also a ‘gray zone,’ where
these kinds of tools become very important.”
Other models have been built to predict who is at risk of
developing sepsis or when to administer vasopressors in the ICU. The
MIT-developed model is the first one to be trained on data from the ER.
“[The ICU] is a later stage for most sepsis patients. The ER
is the first point of patient contact, where you can make important decisions
that can make a difference in outcome,” Heldt said…
“The model basically
takes a set of current vital signs, and a little bit of what the trajectory
looks like, and determines that this current observation suggests this patient
might need vasopressors, or this set of variables suggests this patient would
not need them,” Prasad said.
The researchers hope to expand their work to make more tools
that can predict in real-time if patients in the ER would initially be at risk
for sepsis or septic shock.
“The idea is to integrate all these tools into one pipeline
that will help manage care from when they first come into the ER,” said Prasad.
The researchers also say that the system could help
clinicians in emergency room departments in major hospitals focus on patients
who are most at-risk of developing sepsis.
“The problem with sepsis is the presentation of the patient
often belies the seriousness of the underlying disease process,” Heldt said.
“If someone comes in with weakness and doesn’t feel right, a little bit of
fluids may often do the trick. But, in some cases, they have underlying sepsis
and can deteriorate very quickly. We want to be able to tell which patients
have become better and which are on a critical path if left untreated.” (E)
Jonathan Perlin, MD, president of clinical services and
chief medical officer at HCA Healthcare, calls sepsis an “overwhelming
infection” that can lead to severe organ failure and even death. He says the
key to survival is early recognition and aggressive treatment.
“It’s a medical emergency that should be treated as
aggressively as a heart attack or stroke,” Dr. Perlin said. “At HCA, we’re
pleased to be able to rally the data of more than 28 million patients every
year to help control sepsis, one of the most challenging diagnoses inflicted on
patients, and ultimately, better inform patient improvements and outcomes.”..
For every hour of a delayed sepsis diagnosis, it increases
the chance of death between 4 and 7 percent…
How does SPOT work?
Hospital computers, through “machine learning”, are trained
by ingesting millions of data points on which patients do and do not develop
sepsis. Those computers monitor clinical data every second of a patient’s
hospitalization. When a pattern of data
consistent with sepsis risk occurs, it will signal with an alert to trained
technicians who call a “code sepsis.”
The bedside nurse responds, begins evaluating the patient,
and if sepsis is not “ruled out,” treatment begins immediately.
“SPOT is operating with 100 percent sensitivity, that is,
all true sepsis positives have been identified,” he said, “allowing caregivers
to fully focus on those patients who need intensive monitoring and support.”
More than 5,500 lives have been saved over the last three
years as a result of the stop severe sepsis program, the national standard that
relies on detecting sepsis at the cusp of deterioration, and HCA’s new
technology SPOT.
“The doctors and nurses tell us there were some patients
SPOT detected that we would’ve known about,” Perlin said. “More importantly, it
told us time and again those patients we didn’t appreciate that were headed
towards sepsis.”
HCA celebrated in August 1 million patients followed by
SPOT. (F)
“Durham, N.C.-based Duke University Hospital in November
will launch Sepsis Watch, a system that uses artificial intelligence to help
identify patients in the early stages of sepsis, according to IEEE Spectrum.
Duke University Hospital will deploy the system in its
emergency department before extending it to the general hospital floor and
intensive care unit.
“The most important thing is to catch cases early,
before they get to the ICU,” Suresh Balu, project lead and director of the
Duke Institute for Health Innovation, told IEEE Spectrum.
The Sepsis Watch system can identify cases based on numerous
variables, including vital signs, lab test results and medical histories. The
AI’s training data consists of 50,000 patient records and more than 32 million
data points. While operating, the system pulls information from medical records
every five minutes to evaluate patients’ conditions, which offers real-time
analytics physicians can’t provide.
When the AI system detects a patient who may be in the early
stages of sepsis, it alerts a nurse on the hospital’s rapid-response team who
will either dismiss the alert, place the patient on a watch list or contact a
physician about starting treatment. The system will also walk staff through a
sepsis treatment checklist using protocols outlined by the Surviving Sepsis
Campaign.
“The model detects sepsis,” Mark Sendak, MD, physician
and data scientist, told IEEE Spectrum. “But most of the application is
focused on completing treatment.”
Electronic health records can help identify hospitalized
patients at risk of death, according to a new study in The American Journal of
Medicine.
Inpatients’ conditions can deteriorate quickly; the faster
the intervention, the better the patient’s chances of survival. The
researchers, from Arizona based Banner Health, created an algorithm that looked
for at least two out of four systemic inflammatory response syndrome (SIRS)
criteria, plus at least one of 14 acute organ dysfunction parameters. The
algorithm continually sampled the EHR data in real time of 312,214 patients in
24 Banner Health hospitals, and contained an alert to notify the physician of
the risk of death when a patient triggered it.
The alert identified a majority of the high risk patients
within 48 hours of admission and enabled early and targeted medical
intervention. The patients who triggered the alert had a “significantly
high” chance of dying in that hospital stay compared to patients who
didn’t trigger the alarm.” (G)
“.. the technology that goes by the name AI Clinician,
described today in a paper in Nature Medicine, doesn’t diagnose—it makes
decisions. It takes all the information about a patient with sepsis and
recommends a course of treatment.
“It’s not mimicking the perceptual ability of the doctor,
where the doctor sees certain symptoms and says the patient is going into
septic shock,” says Aldo Faisal, an associate professor of bioengineering and
computing at Imperial College London and one of the paper’s authors. “It’s
really cognition that is captured here. We’re not just making the AI see like a
doctor, we’re making it act like a doctor.”
The researchers didn’t try out their system on real
patients; the technology isn’t ready for the clinic yet. Instead, they trained
and tested AI Clinician on medical record databases from intensive care units
(ICUs) in the United States. They first used 17,000 cases to teach the model
about sepsis treatment, and then had it issue recommendations for 79,000 cases.
Overall, the treatments that the AI recommended were more
likely to keep patients alive than those administered by the human doctors…
Part of the treatment is to give patients intravenous fluids
and drugs called vasopressors that constrict the blood vessels and increase
blood pressure: These actions ensure that blood is reaching the organs.
However, there’s considerable debate about how much to give, and when.
The researchers trained AI Clinician to issue
recommendations on fluids and vasopressors. Gordon says these basic
recommendations are just a start, and that the team has already been working on
a model that includes more treatment factors…
Theoretically, an AI could control electronic pumps that
deliver IV fluids and medications. “It would be the most personal doctor you
can imagine, relentlessly watching over you,” Faisal says…
Essentially, reinforcement learning comes down to trial and
error. The trainers establish a goal—such as winning a game, achieving a high
score, or keeping a sepsis patient alive—and link it to a reward. (In this
case, the AI was programmed to maximize credits, and it earned credits for each
patient that stayed alive and lost credits for those that died.) The AI tries
out a sequence of actions at random, and if it achieves its goal, it gets the
payoff. Over many repetitions, it learns which combinations of actions are most
likely to result in the reward.” (H)
“After finding inefficiencies and a high potential for error
in their sepsis treatment process, University of Utah Health, a four-hospital
system based in Salt Lake City, partnered with clinical communication solutions
provider Spok to help improve sepsis response…
Dr. Horton began to identify problems in sepsis response
while evaluating patients with fevers. “When I was consulting for a fever,
I’d go see a patient, get into their chart and find they had abnormal vital
signs that had been there for several days,” he said. “Our EHR imports
those notes every day, but there were no discussions about those vital
signs.”
At patient bedsides, nurses would take vital signs and
continue this process for four or five other patients, making the first vital
signs up to an hour old by the time they were entered into the computer.
“If this was an emergent case, we’d already lost an hour,” Dr. Horton
said. “There may not be communication about those vital signs, they may
just sit in the computer waiting for the nurse to see them and a provider may
not get back to them quickly.”
Some of the health system’s providers couldn’t put the
pieces together to say it was sepsis, Dr. Horton said. “And as we started
looking into it, we realized we had no real process in place at our institution
to address sepsis as a leading cause of death.”
If there was a way to get the vital signs in the notes sent
to a provider who knows what to do with them, the hospital could ensure
patients aren’t slipping through the cracks, Dr. Horton said.
To address this issue, University of Utah Health leveraged
their EHR system with Spok Care Connect, which takes the EHR’s sepsis alert or
a critical test result and sends it to the right clinicians’ mobile device
automatically.
The alert contains the information clinicians need to act
right away, including who the patient is, their room number and their modified
early warning score, or MEWS. MEWS is a physiological test that prevents delays
in the intervention or transfer of critically ill patients. The alert is sent
in seconds, allowing the care team to respond faster.
University of Utah Health’s EHR automatically uses vital
signs entered to calculate the MEWS score. If the MEWS is sufficiently high,
Spok sends that MEWS alert as a message to either the charge nurse or the rapid
response team. When vitals are outside normal range, the recipients get a
notification to begin intervention on that patient right away.
“What was helpful for us was having all our sepsis data
in one place — we can look at the data and take it back to our providers to
tell them what we’re seeing,” Dr. Horton said. “If you have an
EHR-based algorithm, patients’ illness can be detected earlier on and
resuscitated earlier on.”
The data University of Utah Health collected also allowed
them to look at the odds of septic patients getting antibiotics within the
first 24 hours, Dr. Horton said.
“For all sepsis patients, we saw a length of stay that
was decreased by 10 percent and because of that our total direct cost decreased
by 10 percent.”
“We can have the best hospital in the world, but if you
don’t know what vital signs are, and if the vital signs aren’t entered into the
computer in real time, then that patient is losing, and the institution is
losing,” Dr. Horton said.” (I)
“.. a new alert system, pioneered by doctors at Cambridge
University Hospitals and part of a two-year pilot, has led to a seven-fold
increase in the number of patients getting life-saving drugs.
The alert system works by constantly analysing patients’
observations, as recorded by staff on handheld devices.
This includes temperature, pulse, blood pressure and level
of consciousness taken at various stages as patients are assessed in A&E.
If the observations suggest a patient might have sepsis, a
text message appears on the hand-held device and doctors can treat the patient.
The alert system was introduced at Addenbrookes Hospital in
2016. In July 2015, only 11 per cent of patients with possible sepsis were
given antibiotics within an hour of arriving at A&E. This increased to 76
per cent by August 2016.” (J)
“New York state hospitals’ adherence to sepsis protocols
increased and sepsis mortality declined after reporting became mandatory,
researchers said.
The analysis of sepsis reporting data from 185 New York
hospitals from April 2014 through June 2016 found that sepsis protocols were
initiated in 81.3% of eligible patients, most often in emergency care settings.
Risk-adjusted deaths declined from 28.8% to 24.4%
(P<0.001) among patients for whom a sepsis protocol was initiated, reported
Mitchel M. Levy, MD, of Brown University/Rhode Island Hospital in Providence,
and colleagues in the American Journal of Respiratory and Critical Care
Medicine…
While hospitals have some flexibility in developing their
sepsis protocols, the law requires:
• Blood
cultures followed by antibiotics and measurement of blood lactate levels within
3 hours of presentation in patients with severe sepsis (“3-hour
bundle”)
• Administration
of intravenous fluids (30 cc/kg), vasopressors and re-measurement of lactate
within 6 hours in patients with septic shock, defined as systolic pressure
<90 mm Hg or lactate level ≥4 mmol/L (“6-hour bundle”)..
Greater hospital compliance with 3-hour and 6-hour bundles
was associated with shorter length of hospital stay as well as with increased
survival…(K)
“Despite the controversy, the proof in the literature
is overwhelming,” he said. “The question I have when I debate this
is, ‘Where would you want your loved one to be treated — at a hospital that is
known to be continuously working toward meeting these measures or at a hospital
that doesn’t agree with them?'”
Twenty-seven states fall below the national average for
appropriate sepsis care, according to sepsis performance data added to CMS’
Hospital Compare website in July.
Nationally, the average percentage of patients who received
appropriate care for severe sepsis and septic shock is 49 percent, according to
Hospital Compare.
The sepsis performance measure is based on data from the
first quarter of 2017 through the third quarter of 2017. The preview period for
this change spanned from May 4 to June 2. The first full year of sepsis data
will be available by October.
Here are the states ranked by the percentage of patients who
received appropriate care for severe sepsis and septic shock, ordered from
highest to lowest: • New York: 45 (L)
“Sepsis is a major cause of death in U.S. hospitals, yet
timely and effective sepsis care can reduce the risk of death,” Chanu Rhee, MD,
MPH, assistant professor of population medicine at Harvard Medical School and
Harvard Pilgrim Health Care Institute, said during a presentation.
Previously, Infectious Disease News spoke with Konrad
Reinhart, MD, chair of the Global Sepsis Alliance, about the global rise of
sepsis. Although he said there have been improvements in coding standards in
the last 5 years, before that “the medical system was not doing a good job of
accounting for cases of sepsis.”
Rhee and colleagues found that the reliance on claims data
may be hindering sepsis surveillance, research and quality improvement.
Likewise, Rhee said variations in hospital diagnosis, documentation and coding
practices may make it difficult to benchmark hospital sepsis outcomes using
claims data.
“Administrative claims data have important limitations,”
Rhee said. “We know they have low-to-moderate sensitivity when identifying
sepsis and, more importantly, recent analyses have suggested that claims-based
trends are biased by changing diagnosis and coding practices over time.”..
Rhee explained that varying claims data between hospitals
limits its use when comparing sepsis rates and outcomes.
“I would be the first to acknowledge that there is no true
gold standard for sepsis,” Rhee said. “However, the EHR clinical criteria, I
believe, are more objective and consistent.” (M)
“The Sepsis Alliance is using the month of September to
educate the public and care providers about the dangers of sepsis and the need
to take quick action. By using the TIME acronym, it serves as a reminder to
seek medical attention as soon as symptoms are present.
Temperature – Higher or lower than normal.
Infection – May have signs and symptoms of an infection.
Mental decline – Confused, sleepy, difficult to rouse.
Extremely ill – “I feel like I might die,” severe
pain or discomfort.
If you have a combination of any of these symptoms, see your
medical professional immediately, call 911, or go to a hospital with an
advocate and mention concerns about sepsis.” (N)
“A local hospital is using a lighter approach to educate
staff on a critical problem.
Nurses and doctors at Penn Presbyterian had to solve clues,
just like an escape room game, to properly diagnose and treat a mock patient
with sepsis – a life-threatening response to an infection. And to save him,
they had an hour to complete all the tasks.
A nurse developed the exercise to make colleagues more aware
of how to detect and treat sepsis.
And some of the equipment in the room was just used as a
decoy – trying to make staffers more attentive and think as they would have to
in a real-life situation. No doubt this will help them and their patients in
the future. (O)
“I have been on active surveillance (AS) for prostate cancer
since December 2010. But though I generally am a compliant patient, I increasingly
have become resistant to MRIs and biopsies.
I have had five biopsies since 2010. Only a single core out
of 60 has revealed any cancer — less than one millimeter back in 2010. It was
never seen again.
In the beginning, I had annual biopsies; lately, I have been
on a biopsy vacation.
When I heard about potential sepsis, I became uncertain
about being needled.
I worry about the potential, though rare, for deadly
infections. My hospital takes steps to prevent infections (they have a low rate
in prostate biopsies, one infection in 6,000 patients vs one in 1,500
nationally), but sepsis is a killer.” (P)
“When someone is admitted to the hospital, they expect to
get better. Instead, nearly 100,000 people in the United States are dying each
year because of healthcare-associated infections (HAI), which is more than
breast and prostate cancer fatalities combined.
Those who acquire HAIs but survive are forced to stay in the
hospital for significantly longer than those who do not receive an infection,
racking up medical bills that likely could have been avoided.
According to the Center for Disease Control (CDC), there are
four common types of HACs:
Catheter-associated urinary tract infection (CAUTI): This is
a type of infection that can occur in any part of the urinary system. The
biggest risk factor for a CAUTI is using a catheter for too long. Doctors
should remove them as soon as they are no longer needed to minimize this risk.
Central line-associated bloodstream infection (CLABSI):
CLABSI is a serious infection that occurs when germs enter the bloodstream
through a central line, which is a tube that doctors place near large veins to
give medications or fluids or collect blood for testing.
Surgical site infection (SSI): An SSI is an infection that
occurs after a surgical procedure at the part of the body where the surgery
took place.
Ventilator-associated pneumonia (VAP): VAP is lung infection
that develops in individuals while they are on ventilators to help them
breathe.
Many HAIs are a result of a doctor failing to follow proper
medical procedures. Making errors during surgery, using poor hand hygiene,
using materials that are not sterile, improper insertion of a catheter or
central line, and failure to remove devices in a timely manner are just some of
the ways medical providers can cause HAIs.” (Q)
“Early Recognition of Sepsis across the Continuum. “To
facilitate timely diagnosis and management, healthcare organizations across the
continuum should have protocols for response when sepsis is suspected, much as
they do for chest pain.”” (R)
“In a recent national survey of more than 1,300 EMS
providers, the National Association of Emergency Medical Technicians (NAEMT) in
association with the Sepsis Alliance found that although nearly all respondents
(98%) consider sepsis a medical emergency, only about half (51%) feel very
confident in their ability to recognize symptoms of sepsis—the body’s
life-threatening response to an infection…
Unfortunately, more than one third of EMS providers surveyed
say that sepsis isn’t a key priority within their organization, and 33% say
their organization isn’t well prepared for patients with sepsis. Furthermore,
25% state that while they know patients have sepsis, physicians don’t like to
diagnose them with it, and 58% say when patients are showing signs of sepsis,
not all hospitals initiate a sepsis protocol.” (S)
“UK researchers have developed a test they say might quickly
identify sepsis, a potentially fatal complication from an infection.
Scientists at Scotland’s University of Strathclyde developed
an experimental microelectrode device that analyzes a patient’s blood and
provides results as quickly as 2.5 minutes. Current testing methods for sepsis
can take up to 72 hours.
This is important given that every hour without diagnosis
and treatment increases the chance of dying.” (T)
Can You Really Get Sepsis from Trying on Shoes Without
Socks? (U)
Famed Renaissance painter Caravaggio didn’t die of syphilis,
as some historians long thought.
Instead, it appears that the talented Italian artist — who
had a reputation for gambling, drinking, sleeping with prostitutes and even
murder — died of a sword wound that developed a nasty infection, leading to
deadly condition called sepsis, a new study finds. Sepsis is the body’s
overwhelming and life-threatening response to an infection.
A team of French and Italian scientists made the discovery
by digging up and analyzing what they believe are the skeletal remains of the
revolutionary painter, who died at age 39 in 1610. [Photos: Renaissance
Husband’s Heart Buried with Wife]..
Over the years, historians have speculated how the artist
died. Caravaggio had a fever at the time his death, prompting some to guess
that he had malaria or even brucellosis, an infection that people can get from
eating unpasteurized dairy products.
To investigate, the researchers searched the cemetery
reported to hold Caravaggio’s remains. They looked for a skeleton that was
about 5 feet, 4 inches (1.65 meters) tall and between 35 and 40 years of age.
Nine skeletons in the cemetery met these criteria, but only
one dated to the beginning of the 17th century, according to radiocarbon
dating, the researchers said. Even more revealing were the high levels of lead
in the bones, “which was a discovery of great importance since Caravaggio
was known to be careless when using lead for painting,” the researchers
wrote in the study, published online Sept. 17 in the journal The Lancet.
The research team also analyzed the individual’s DNA and
found that it matched the genetic profile of other men with the name Merisi or
Merisio, who are believed to be Caravaggio’s relatives.
Satisfied they had Caravaggio’s remains, the researchers
next analyzed his teeth and found the bacteria Staphylococcus aureus hiding
within the remaining blood vessels of the artist’s teeth. This bacterial
infection likely led to Caravaggio’s sepsis, the researchers said.
“[The cause of death] resulted from sepsis secondary to
superinfection of wounds after a fight in Naples, a few days before the onset
of symptoms,” they wrote in the study.” (V)
“The cost of treating patients who develop sepsis in the
hospital rose by 20% in just three years, with hospitals spending $1.5 billion
more last year than in 2015, according to a new analysis.” (X)
Prequel:
“…of the 1.5 million Americans who develop sepsis each year,
nearly 260,000 die from it.”
1. RESPONDING TO HEALTHCARE REFORM – A Strategy Guide
for Health Care Leaders, By Daniel B/ McLaughlin, HAP ACHE Management
Series Read one chapter per week
starting with Chapter 1, Week
2. Harvard Case Studies
The Cradle Dilemma, kel511
Performance Management at Intermountain Healthcare,
HBS 9-609-103
Newton-Wellsley Hospital, HBS 9-609-088
Evidence-Based Management, HBS R0601E
What More Evidence Do You Need?, HBS R1005X
Collaborating to Improve, HBS 9-608-054
Jeanette Clough at Mount Auburn Hospital, HBS
9-406-068
3. Additional readings posted on Blackboard; Web sites
are also assigned for some sessions.
4. “Doctor, Did You Wash Your Hands?” http://hoboken.patch.com/blogs/metsch-on-health-care
Visiting Professors
(* Program Graduate)
Jeffrey Kraut*
Senior Vice President for Strategy of the North Shore-LIJ
Health System and Associate Dean for Strategy for the Hofstra North Shore-LIJ
School of Medicine
– “North
Shore-LIJ Health System’s strategy to maintain its leadership
position under health care reform”?
Frank Goldstein*
Vice President, Physician Services, Meridian Health
– “Converting
hospital based physician practices from FFS to Patient Centered Medical Homes“
Annette Catino*
President & CEO, QualCare Alliance Networks, Inc.
– “Obamacare from the Payers perspective“
Carmine Asparro*
Principal in charge of the managed care consulting practice,
OnPoint Partners
– “Provider and health plan strategies with Health
Insurance Exchanges“
David Florman*
Partner of Florman Tannen LLC
– “Population health management – organizational
transformation in the health care reform era“
Jeffrey Menkes*
Senior Vice President ,System Network Development,
Montefiore Medical Center
– “Lessons Learned as a
“seller” now “buyer” under Obamacare“
Joel Seligman
President and CEO of Northern Westchester Hospital
– “Northern
Westchester Hospital Center’s strategy to maintain its leadership
position under health care reform“
Lee Perlman
Executive Vice President of Administration and Chief
Financial Officer of the Greater New York Hospital Association; President of GNYHA Ventures, Inc.; and CEO of
Happtique
– “Creating Value: GPOs and the Business and Politics of Health Care”
Section Objectives
To learn the basics about the American health care system
To understand the implications of the Affordable Care Act
To learn to use the Case Study method as an analytical tool
To start using an “evidence-based” approach to management
To be a successful
contributor in small group meetings
To get comfortable
being a discussion leader
To meet and interact with industry leaders (your future
bosses)
To begin a personal career diary of “Lessons Learned”
Section Paradigm
Using the CASE STUDY METHOD the course presentations by
Professor Metsch and the Visiting Professors address COMPLEX PROBLEMS and the
value of LESSONS LEARNED.
Case Study types: original Case Studies prepared by Prof.
Metsch; Case Studies presented by senior health administrators (Visiting
Professors); and iconic Harvard Case Studies.
Sessions are comprised of two complementary parts paired to
integrate the Case Studies with Student Learning Outcomes and the Course
Objectives.
The Case Study Method
Cases attempt to reflect the various pressures and
considerations that professionals of all varieties confront in the workplace.
Using complex, realistic open-ended problems as a focus,
cases are designed to challenge you and help you develop and practice skills
that you may need in your future careers.
Cases are also an excellent way to see how abstract
principles learned in class are applied to real world situations.
Remember that case assignments involve a different kind of
learning than other assignments. There is no one single answer and sometimes
even the issue is deliberately not stated clearly.
Complex Problems
situations where the decision-maker must integrate or
reconcile at least two competing priorities that may not be linear or
complementary
having to reach agreement on goals while simultaneously
evaluating options
where goals are clear but political support is not
where the definition of the problem keeps changing and
consensus has to constantly be reestablished
where there are so many variables it is difficult to
determine the actual possible outcomes
various combinations/ permutations of the above
Lessons Learned
Start a diary of 3 Lessons Learned each week from the
following categories:
• – the Visiting Professor and/
or ProfM
• – the course text – RESPONDING TO HEALTHCARE
REFORM
• – the articles posted on Blackboard or articles
you find yourself
• – a Harvard Case Study (but only if different
from the LLs you used in your 8 slide set)
• – an experience at work or elsewhere
•
• USE 3 DIFFERENT CATEGORIES EACH WEEK!
• For Week 12 use LLs
from Final Case Study presentations ONLY (but not your
own)
• then synthesize them
into a Lessons Learned essay after the last class
Objective of Case Study Analysis =
To develop an evidence based theme (“thread”) through the slide set so the conclusion (“policy recommendation” or “project plan”) is accepted
How to Structure Your Harvard Case Study Homework
Assignments
& Final Case Study Project
USING POWERPOINT (one slide on each of the following)
1. Introduction,
Situation, Background -This section describes the reason for the case study.
2. Problem –
This section states the main problems which need to be resolved. Some case
studies include charts and graphs to illustrate key points.
3. Questions/
Issues*
4. Solution
– This section describes the solution in detail, what changes were made, and
the impact. Some case studies include charts and graphs to illustrate key
solutions.
5. Evaluation
– This section recap the main benefits of the solution and the impact/
outcomes/ results.
6. Lessons
Learned!
7. Anchor
Concepts
8. Overlay 2013 ACA and “transformational”
(if case was taking place today)
*Note: For final Student Case Presentations – #3 Questions/ Issues for class discussion before presenting #4 Solution
Week 1 – December 3rd
Case Study Method 1
Professor Metsch
“Project Management – The Hardest Part about Getting
Started………… is Getting Started”
(7 health care
related vignettes with break-out groups to understand and practice case
study analytics)
1. Getting Started –
“The First Day”
2. Program Planning –
Hoboken H1N1 “Swine Flu” Task Force
3. Service Recovery –
Hospital ER
4. Professional
Status – When the Nurse Wants to be Called “Doctor”
( 3 integrated health care related vignettes with
break-out groups to further understand and practice case study analytics)
Homework* The Cradle
Dilemma kel511
(a health care related NFP CEO grapples with its “mission” in a turbulent environment)
Week 3 –December 17th
Case Study Method 3
Professor Metsch
Jersey City Medical Center (1989-2013)
( an original case study based on Dr. Metsch’s 17 year
tenure as President and CEO of LibertyHealth/ Jersey City Medical Center, with
break-out groups; to finish practicing case study analytics)
(a CEO faces the challenge of multiple physician payment methods in one hospital)
Week 7 – January 28th
Jeffrey Kraut
Senior Vice President for Strategy of the North Shore-LIJ
Health System and Associate Dean for Strategy for the Hofstra North Shore-LIJ
School of Medicine
– “North
Shore-LIJ Health System’s strategy to maintain its leadership
position under health care reform”?
(A case study on the transformation of the Health System’s
clinical and business models to succeed under value-based health reform.)
Case Study Method 5
Professor Metsch
Evidence Based Decision Making
(fostering a framework for inter-disciplinary
collaboration)
Reading
Evidence-Based Management – HBS R0601E
What More Evidence Do You Need? – HBS R1005X
Week 8 – February 4th
David Florman
Partner of Florman Tannen LLC
– “Population health management – organizational
transformation in the health care reform era“
(a health care consultant presents case studies on
organizational adaptation)
Homework*
Collaborating to Improve HBS 9-608-054
(a hospital Chief Medical Officer’s efforts to introduce a
new quality paradigm)
Homework*
Collaborating to Improve HBS 9-608-054
(a hospital Chief Medical Officer’s efforts to introduce a new quality paradigm)
Week 9 – February 11th
Lee Perlman
Executive Vice President of Administration and Chief
Financial Officer of the Greater New York Hospital Association; President of GNYHA Ventures, Inc.; and CEO of
Happtique
– “Creating
Value: GPOs and the Business and Politics of Health Care“
(a senior health care trade association executive discusses
creating new revenue streams for its members)
Case Study Method 6
Professor Metsch
The role of the Board of Trustees
(a series of vignettes on “best practices” of NFP Boards of
Trustees)
1. “Raw” Curated Contemporaneous Case Study Methodology by Jonathan M. Metsch, DR.P.H.
0RecommendJonathan Metsch, Dr.P.H Posted 05-24-2018 16:03 Edited by Jonathan Metsch 07-19-2018 23:13 ReplyOptions Dropdown
I taught full time in the Baruch MBA in Health Care Administration program from 1972 to 1975, then was a health care administrator for over thirty years, finishing for seventeen years as President & CEO of LibertyHealth/ Jersey City Medical Center, where we built a replacement safety-net hospital (it took 15 years), played a key role on September 11th, 2001, and once again became a medical school affiliated teaching hospital (having been free-standing for decades). After retiring from LibertyHealth, I returned to the Baruch program for four years as Adjunct Professor and started writing case studies. I developed case studies based on my CEO experiences. Interestingly case studies on failures provided better Lessons Learned than cases on successes. I also used Harvard Case Studies, and invited “Visiting” Professors to present cases typically related to the new realities of Obamacare, mostly C-Level executives I was still in touch with from my first stint at Baruch. I was very proud of what they had accomplished and shared. In retirement I have watched health care disruption become so complex that there are few, if any, up-to-date case studies. So I developed a method of “raw” contemporaneous cases studies each developed by curating news articles into a coherent thread, after a topic has called out to me. Topics come from navigating the system (think out-of-network physicians, for example), news feeds, and friends and family. Now, my Career Capstone Project is to bring “raw” cases to AUPHA that can be used in real-time, meaning they can start a discussion for immediate use in class. For example if I was teaching now I would be doing a contemporaneous cases on the opioid crisis, tracking the implications of medicinal/ recreational marijuana, and the stealth plan to reintroduce Trumpcare before Congress adjourns for the mid-term election.
E. Then every day from your News Feeds select articles on
your topics and move them to the appropriate folder.
F. When you are inspired to write a “case” start a
Word document, then go to the case folder and select key points from the
articles, and cut and paste them to the Word document. As well capture article
title, author and hyperlink.
G. Move the key points around until you have created a
story.
H. Then label each point A,B.C…and move article title,
author and hyperlink to footnotes at the end of the case.
Cases are narratives, situations, select data samplings, or
statements that present unresolved and provocative issues, situations, or
questions (Indiana University Teaching Handbook, 2005). The case method is a
participatory, discussion-based way of learning where students gain skills in
critical thinking, communication, and group dynamics. It is a type of
problem-based learning.
Often, executives are surprised to discover that the
objective of the case study is not to reach consensus, but to understand how
different people use the same information to arrive at diverse conclusions.
When you begin to understand the context, you can appreciate the reasons why
those decisions were made. You can prepare for case discussions in several
ways.
A major advantage of teaching with case studies is that the
students are actively engaged in figuring out the principles by abstracting
from the examples. This develops their skills in: Problem solving; Analytical
tools, quantitative and/or qualitative, depending on the case; Decision making
in complex situations; Coping with ambiguities
It’s difficult to find a good set of resources for teaching
online case studies. While researching how to structure and moderate online
case studies for one of our faculty members, I put together a list of several
resources. Hopefully, you’ll find these a helpful place to start as you are
learning to teach using case studies online.
Whether you’re new to distance learning or an experienced
online teacher, you can find free online training resources to fit your needs.
Are you a “face to face” classroom teacher
considering shifting to online education?
Or are you an online teacher interested in the latest
technology to make your online courses more effective?
For example, some online schools offer free training modules
to help campus-based teachers learn how to transition to cyber-classrooms.
Other organizations offer tips on designing online classes and teaching with
technology.
