Utilization isn't the problem
The recent decision by the national Blue Cross and Blue Shield Association to blame providers for rising healthcare costs is disappointing ("Battle of the cost reports," Oct. 28, p. 6). Although a careful read of the study clearly suggests that utilization, new medical technology and labor costs are the most significant cost drivers, the Blues group apparently made a calculated decision to point the finger at the emergence of integrated delivery systems as the leading cause behind double-digit healthcare cost increases.
The Wisconsin Health and Hospital Association recently undertook a similar analysis of Wisconsin data and found that increased utilization of all categories of healthcare services is driving healthcare costs higher. Our findings were released in an educational format instead of fingering "culprits" in a "sound bite"-packed press release. We noted that increased utilization is not necessarily bad and that consumers should not be blamed for accessing new technology, prescription drugs and preventive healthcare services that, in the long term, can improve health status and lead to a higher quality of life.
We've taken the position that our association has an obligation to educate the public-especially stakeholders engaged in influencing public policy-as to the real factors driving rising healthcare costs. Armed with facts, we're certainly more able to seek meaningful solutions to this hugely complicated and multifaceted issue.
And speaking of solutions, is it possible that the national Blues association's criticism of provider consolidation may really be aimed at shutting down successful provider-owned health plans that have emerged from integrated delivery systems? In Wisconsin, these award-winning plans provide real competition to traditional insurance companies, competition that provides choices to consumers, a focus on wellness and disease-management strategies that have a positive impact on dampening rising healthcare costs.
Wisconsin Health and Hospital Association
The real cost drivers
Your article "Battle of the cost reports" (Oct. 28, p. 6) is certainly slanted toward the payer's perspective. I would like to answer the charge that hospitals are the main cause of rising healthcare costs from my perspective in the inpatient hospital arena.
There has been a multitude of hospital closures in recent years. That fact alone should lead you to ask, "If hospitals are increasing healthcare costs so dramatically, why are hospitals closing?"
In reality, hospital reimbursements have dropped continually for the past decade, and the vast majority of reimbursements hospitals do receive is from low DRG rates that hardly give hospitals much of an operating margin.
Public and private payers cause the real problem. The amount of red tape providers must wade through in order to receive just payment for patient care has greatly increased administrative costs. Yet because of their narrow operating margins, many hospitals haven't been able to put into place the sophisticated electronic medical records needed to capture reimbursement. This allows much inefficiency to continue, leading to a significant overlapping of orders within the hospital and duplicate testing. These repeat tests cut into the hospital's net revenue and cost per case. They do not cause increased reimbursement.
The Food and Drug Administration's approval of some very expensive medications that have marginal benefit drives up costs as well. The manufacturing companies spend a lot of money to get physicians to use these drugs, while hospitals don't have the resources to educate physicians and consumers on why they don't need them.
Your article fails to address the roots of healthcare costs, and thus the assigning of blame is superficial and misleading.
Physician director of quality improvement
St. John Oakland Hospital
Madison Heights, Mich.
Working together on stents
In your story on drug-eluting stents "Stuck in the middle" (Oct. 21, p. 4), you indicate that "the CMS and manufacturers are barreling down the highway with their eyes closed" to the revenue impact on hospitals. But doesn't the story make exactly the opposite point? In great detail, it relates how the Centers for Medicare and Medicaid Services has its eyes wide open to the benefits of this breakthrough treatment, while hospitals are analyzing the losses they face as a result of fewer open-heart surgeries, which are more profitable for them but more invasive, more traumatic and higher-cost.
As partners in the delivery of healthcare, the mutual goal of Medicare, hospitals, doctors and manufacturers always must be to provide patients the highest quality, most affordable care possible.
The CMS displayed an exceptional level of responsiveness to this new, cost-effective technology by improving reimbursement prior to Food and Drug Administration approval. Although this reimbursement level still may not cover the total upfront costs for some hospitals, it is a major step in the right direction.
Hospitals need to work proactively with private payers to achieve adequate reimbursement for new technologies that will improve quality of life and productivity for their members. The "new technology" clause in contracts with payers that you cite is one good way to do this.
The alternative tactics discussed in your story-restricting access to drug-eluting stents or bringing more patients back into the hospital for multiple procedures-are not the answer. The fact that hospitals feel constrained to take such measures clearly illustrates why we must work together to improve Medicare policy to ensure that hospitals receive timely, adequate reimbursement for drug-eluting stents and other new medical technologies and procedures.
Advanced Medical Technology Association
Why not us?
I was troubled by your lack of inclusion of St. Francis Hospital in Roslyn, N.Y., as one of the 100 top cardiovascular hospitals in the U.S. ("Strong at heart," Oct. 21, p. 26).
St. Francis in the past several years has consistently performed approximately 2,500 open-heart procedures per year, making it the busiest cardiovascular surgical program in the Northeast. St. Francis leads New York state in the number of bypass surgeries it performs each year, according to recent data from the state health department. In 1999, the hospital performed 1,804 bypass procedures and the hospital's risk-adjusted mortality rate for all those patients was 1.29%, compared with a statewide average of 2.25%.
Lawrence Reduto, M.D.
Executive vice president of medical affairs
St. Francis Hospital Heart Center
Questions for the JCAHO
David Burda's editorial regarding the "new" Joint Commission on Accreditation of Healthcare Organization's latest makeover, "Deja vu all over again?" (Oct. 14, p. 22), is not without merit. Another change in approach to the accreditation process leaves little doubt of the limited effectiveness of past commission survey techniques.
Printed jabs keep the spotlight on the problem but don't focus intellect toward a solution. Any discussion of third-party, "independent" auditing of a hospital's ability to provide a safe environment for patients, by necessity, must begin with definition. Once defined, measurement is undertaken, processes are reviewed and corrective actions are promulgated.
The industry continues to struggle with the definition and measurement of quality care. Past surveys dealing with issues relating to environment, physician credentialing, etc., have probably helped force some needed improvements. But are core issues being addressed? Is healthcare being provided by nurses, technicians, therapists and doctors who would be better off doing something else? Are these caregivers receiving education on the latest proven methods? Are there major flaws in the delivery processes that leave patients at risk? Do hospital leaders demonstrate as much focus on quality as they do finances? No margin, no mission. Bad product, no margin.
Corporate chief executive officers and chief financial officers now must attest to their financial statements. Are hospital administrators ready to attest to quality of care if so mandated?
Answer the call
Neil McLaughlin's Oct. 7 editorial "Declare war on lack of health coverage" (p. 24) is a call to action that we should heed. Last year's 1.4 million increase in the number of uninsured should serve as a siren call to all involved in the intricate world of healthcare policy.
The American Academy of Family Physicians has long fought for healthcare coverage for all. Our experience with this issue has helped us develop a plan that ensures basic coverage for all people living in the U.S. It's based on three principles:
* Basic healthcare services and protection against catastrophic costs would be guaranteed to everyone.
* Healthcare would be funded through a national, broad-based taxing mechanism. Everyone would benefit and everyone would share the expense.
* The current insurance market would be maintained including employer-based and individually purchased insurance. People would have the choice to opt out of coverage for services above the basic benefit but below the threshold for catastrophic protection.
More than 41 million Americans are living without health insurance. McLaughlin is right in calling this a "moral embarrassment." To read the AAFP proposal, go to aafp.org/unicov.xml.
James Martin, M.D.
American Academy of Family Physicians
Deficits and accountability
Although I agree with Todd Sloane's editorial comment that Congress has left a legacy of inaction on healthcare issues ("Where there's no will, there's no way," Oct. 28, p. 32), his political colors come shining through when he states, "We got a tax cut that has driven us back into deficit spending."
Allowing more people to keep money they have earned is not why we have deficits. We have deficits because of a Congress that has increased spending and not adjusted to the reality of a poor economy. When you or I have less income, we have to adjust our spending accordingly or we increase our debt-the same goes for our country. Our politicians would rather use the deficit as a political issue to denounce the tax cut and blame those who advocated the cut.
The only healthcare item that seems to be a hot-button issue this year has been a Medicare prescription drug benefit, but even with that item, politicians have chosen to make it an election issue rather than solve the problem. And so the healthcare sector has taken a back seat to spending increases on a long list of additional spending aimed at helping our politicians get re-elected.
As leaders in the healthcare industry, it is our responsibility to make sure that both politicians and voters realize the problems we are facing and what problems are right around the corner.
Chief operating officer
Call off the style police
Regarding your decision to not use the "RN" credential after someone's name (Sept. 23, p. 21): Funny, I just checked the 2002 Associated Press Stylebook and can't find any such prohibition. Whatever. Language and usage changes with time. Why not lead the ascent to parity instead of contributing to an irrational status quo?
Back in the Dark Ages, I worked at a big Boston medical center where the nurses often threatened to strike. My supervisor would remind me not to forget "what side I was on" when talking to the media. Well, it should be obvious that we're all on the same side now. We need to learn how to spell r-e-s-p-e-c-t soon, or there'll be no one left to care for us when we become patients.
So, folks, let's give the style police a holiday and put an "RN" after the name of everyone who earned it.
P.S.: Thanks to Joyce Sensmeier, RN; Brenda Nevidjon, RN; Cynthia Howe, RN; Tobie Olsan, RN; and Kay Ann Hamilton, RN, for their letters to the editor on this topic in the Oct. 28 issue (p. 38).
Solana Beach, Calif.
For further information
Re your article about HCA's image-based billing-management system, "Centers of attention" (July 22, p. 26): What vendor did HCA use and how can I get more information about that company?
Executive director of medical enterprises
Editor's note: HCA uses a software program called Onbase, created by Hyland Software. The company is based in Cleveland. For more information, see the firm's Web site for the product, www.getonbase.com.