Next steps

Our challenge is to make sure reform's foundation supports and advances what hospitals are doing across the country to make care safer and more efficient, effective and transparent. That is the other story of health reform—the often untold story of how many in the hospital field are carrying out community-based initiatives that are improving care and lowering costs, based on best practices that can be replicated nationwide.

The American Hospital Association's bellwether strategic initiative, Hospitals in Pursuit of Excellence, encourages and promotes these hospital-led initiatives. Our purpose is to share and distribute the very best ideas and practices from within our community to our colleagues in hospitals and health systems of every size and shape, and to the public so they can see the strides that are being made.

The focus initially is on six areas: healthcare-associated infections, patient throughput, medication management, patient safety, health information technology and care coordination. These areas can produce substantial patient and financial value.

The initiative seeks to show how to promote efficiencies, optimize the use of resources and enhance hospitals' ability to deliver safe, high quality and affordable patient care. Its principles are driving national collaborative projects, like the effort to gain broad-scale adoption of a proven checklist to eliminate central line-associated bloodstream infections.

The Michigan Health & Hospital Association and Johns Hopkins University launched this initiative in 2005 to reduce the rate of infections in more than 100 Michigan intensive-care units. The Agency for Healthcare Research and Quality last fall awarded nearly $7 million to the AHA's Health Research & Educational Trust to allow hospitals in all 50 states to participate in the project. (For more information, see onthecuspstophai.org.)

By using the checklist, Michigan hospitals are saving an estimated 1,500 to 1,700 lives a year and eliminating an estimated $200 million in costs annually. Just think what we can do when we multiply that success by 50 states.

Realizing reform's true potential means building a firmer foundation for these and other efforts to improve quality and care coordination, promote innovation and reduce costs. It means removing the regulatory barriers that stand in the way of clinical integration among hospitals, physicians and other caregivers.

The Institute of Medicine's seminal work on quality created a framework that has become a mantra: care that is safe, effective, efficient, timely, equitable and patient-centered. Achieving the IOM's quality goals demands that hospitals and physicians work together as never before.

Like so much else in healthcare, clinical integration should be easier than it is. But legal obstacles remain. The AHA has focused on five in particular:

Complicated antitrust laws hinder caregivers' ability to readily understand how they can work together to improve quality and efficiency. The AHA has advocated that the antitrust agencies—the Justice Department antitrust division and the Federal Trade Commission—issue user-friendly guidance that clearly explains what issues must be resolved to ensure that clinical integration programs comply with antitrust law.

The Ethics in Patient Referrals Act, better known as the Stark law, has drifted from its original intent of preventing physicians from referring their patients to a medical facility in which they have an ownership interest. The law requires that compensation for providers be fixed in advance and paid only for hours worked. As a result, payments that are tied to achievement in quality and efficiency—instead of hours worked—do not meet the law's strict standards.

The Civil Monetary Penalty Act also has drifted from its original purpose of prohibiting hospitals from rewarding physicians for reducing or withholding services to patients. Today's interpretation prohibits any incentive that decreases the amount of care a physician delivers, even if it's the result of evidence-based quality guidelines.

Anti-kickback laws originally sought to protect patients and federal health programs from fraud and abuse by making it a felony to knowingly and willingly pay anything of value to influence the referral of federal health program business. Today, the law has been stretched to cover any financial relationship between hospitals and physicians, which clearly puts a chill on clinical integration.

Internal Revenue Service rules prevent a tax-exempt institution's assets from being used to benefit any private individual, including physicians. The difficulty arises because not every payment from a tax-exempt hospital to a tax-paying doctor violates the tax code and IRS rules. But until the IRS issues guidance on the subject, tax-exempt hospitals have no assurance of how the IRS will rule in a particular situation, including on payments as part of a clinical integration program. That uncertainty can be a significant deterrent to clinical integration.

By bringing the healthcare rules and regulations governing clinical integration into the 21st century, Congress and the administration can build on health reform's foundation and support improvements already under way across America's hospitals that are reducing costs and enhancing the quality of care.

Richard Umbdenstock is president and CEO of the American Hospital Association.