Voices in Healthcare

This weekend's story in USA Today on the growing trend of hospitals across the country refusing to hire smokers is welcome news to start 2012. The Massachusetts Hospital Association became one of the first small businesses to stop hiring smokers more than a year ago, and it's extremely gratifying to see this important practice catching on with larger employers, particularly in healthcare.

As the new model Medicare ACOs demonstrate, now more than ever hospitals are being held accountable to improve the health of the populations they serve. It's commendable that they start by being role models and "walking the talk" on this huge driver of mortality and cost.

Employers - especially hospitals - are to be commended for making sure their employees share their commitment to health.

Massachusetts has a very real - and achievable - opportunity to improve the overall health of our residents and lower healthcare costs at the same time, and we should move forward with this effort as soon as possible. With today's intense focus on the costs of healthcare, and the pressures being exerted on providers to bring those costs down, MHA and our member hospitals are working hard on the downstream side of the equation and making real progress. But the issue needs to be addressed on the prevention side as well, and we should start with one really obvious tactic - ending the state sales tax exemption on sweetened beverages and candy.

Numerous scientific studies have shown that consumption of soft drinks is associated with poor diet, increasing rates of obesity and risk for diabetes. One study found that for children, each extra can or glass of sugar-sweetened beverage consumed per day increases their chance of becoming obese by 60 percent.

Massachusetts state law exempts certain food products from the sales tax. This includes essential items like fruits, vegetables and milk, but it also currently includes soft drinks, sugar and sugar products, and candies. In the last decade, the percentage of calories consumed by 2- to-8-year-olds from sweetened beverages has increased, while the percentage from milk has decreased.

What's wrong with this picture?

Over 40 states now have sales tax on soft drinks and Massachusetts remains one of only a handful of states that does not tax these items at all. HB1697 eliminates the sales tax exemption for candy, confectionary and soft drinks. The Massachusetts Department of Revenue estimates that lifting the sales tax exemption for soft drinks and candy could generate $52 million in annual revenue that could be used for proven public health prevention efforts. A recent poll showed 69 percent of Massachusetts residents would support ending the sales tax exemption on sweetened beverages and candy if the revenues generated went to local schools to help combat childhood obesity.

Opponents of HB1697argue that it amounts to a penalty tax on sugary drinks and candy, but this argument misses the mark. The current exemption is actually a taxpayer subsidy of items that have little nutritional value and have been linked to the growing epidemic of overweight and obesity.

This week MHA joined our fellow members of the Healthy People/Healthy Economy Coalition at the State House to call for an end to the state sales tax exemption for soft drinks and candy. To further educate the public on the dangers of consuming large quantities of sweetened beverages, pediatricians will be handing out "prescriptions" to patients and their parents that describe the negative health effects of consuming too many sugary drinks. MHA will be supporting this education campaign as well.

If we want to lower healthcare costs, we need to support prevention efforts along with payment and care delivery reform. There are a number of ways to support improvements to our residents' public health - Ending what amounts to our Commonwealth’s taxpayer subsidy on sugary beverages and candy would be a concrete step in the right direction.

Today's story in the Boston Globe that Massachusetts insurance costs have dropped from number 1 in the US to number 9 is very good news. Hospitals throughout the Commonwealth, however, are not particularly surprised. Hospitals only account for approximately 39% of our per capita healthcare expenditures, but they are already bending the cost curve, reducing expense increases in 2009 and 2010. In other words, hospitals are helping to move the market in the right direction.

But healthcare costs aren't solely the problem of providers – we all have a responsibility to help reduce costs and premiums. Our state government must also hold itself accountable for improving price variation by paying adequately for care provided through Medicaid and other public sources, and by ending government cost shift to providers and private insurance premiums. We must be careful not to "over-correct" and end up with a situation that is actually detrimental to the healthcare community and the patients we serve.

Government definitely has a role in prompting change in the healthcare market, but that role shouldn't be to determine what rates are given to those who provide care. Recent Massachusetts laws, including M.G.L. Chapters 58, 288 and 305 are examples of constructive government involvement.

We know that price variations in healthcare exist. They exist not only in Massachusetts, but also in highly regulated environments such as Medicare and the state of Maryland, which has mandated government control over provider prices for years. The reasons for variation are complex, and more study is required to understand why particular variations exist and to determine what - if anything - needs to be done about those differences. To act before we understand the significance of variations and what to do about them is placing the cart before the horse.

I sat on the Governor's Special Commission on Provider Price Reform, which recommended that an expert panel be convened to research the many factors for variation and then determine how to reduce any unacceptable variation in provider prices. On behalf of the state’s hospitals, I voted to support this effort. In fact, MHA supported five of the six Special Commission recommendations. But I voted against the recommendation to regulate provider prices from the get-go, for the reasons I’ve mentioned here, as well as in my detailed statement to the Special Commission.

Today's report from The Commonwealth Fund found Massachusetts healthcare premiums are no longer the most expensive in the nation, and that is a great start – It's also evidence that the market's efforts to slow the cost of healthcare increases are working, and that government intervention in price regulation would be premature. But the report also highlights that there is still plenty left to do to slow and reduce healthcare cost increases. Massachusetts hospitals are contributing to the cost-control effort, and will do even more moving forward. Collaborating with all healthcare stakeholders including government, insurers, businesses and their employees, I am confident we can succeed.

The Massachusetts Hospital Association strongly supports mandatory flu vaccination for all hospital employees and applauds Beth Israel Deaconess Medical Center and Children's Hospital Boston for their bold decision to require flu vaccination as a condition of employment.

Today's release of vaccination rates at Massachusetts hospitals shows continued improvement, with 70.8 percent of acute care hospital workers statewide receiving the flu vaccine last year, compared to 68 percent the year before. But 20 percent of those hospitals' employees refused to be vaccinated, which is completely unacceptable and a huge disservice to patients.  There are rare instances where an exception needs to be made, but outside of those limited circumstances, the goal should be 100 percent.

Currently Massachusetts hospitals are required as part of their licensure to ensure that every employee is offered influenza vaccination unless such employee declines to be vaccinated. Hospital employees who decline vaccination are required to sign a form that includes providing the reason the individual refuses to be vaccinated against influenza.

Hospital employees are the front-line stewards of public health and we are proud of their service. For the relatively few employees without extenuating circumstances who may still hesitate to participate in the vaccination program, we believe that their commitment to patient care should carry the day. Patient safety shouldn’t be optional and that means that vaccination compliance shouldn’t be optional either.

Yesterday's excellent op-ed by Senator Richard T. Moore (D-Uxbridge) takes thoughtful issue with several points expressed in an editorial earlier this week by the GateHouse News Service (publisher of the MetroWest Daily News, Milford Daily News, and Taunton Gazette, among others) regarding Massachusetts healthcare reform and the intertwined issues of access and costs. Senator Moore's comments are right on the mark, and could even be expanded upon from the perspective of the hospital and provider community.

The GateHouse editorial's contention that Massachusetts' 2006 healthcare reform law "included no provisions that would keep costs down" is indeed incorrect – as Senator Moore points out. In addition to the points raised by the Senator, the initial editorial omitted mention of another key provision of that statute: The 2006 reform law also included a commitment from the Commonwealth to close the gap between what it paid providers under Medicaid and the actual costs of providing that care. Reducing this underpayment gap would lessen the need for cost-shifting to private insurance, which in turn would mean fewer costs passed on to employers and their workers in the form of higher premiums. Unfortunately the underpayment gap is now larger than it was when the reform bill was enacted. It will be essential for the Commonwealth to re-commit to this priority if any "payment reform" initiative is to be successful.

Big changes are already happening in the healthcare marketplace – and our hospitals are doing their part. Massachusetts hospitals have already cut some $3.1 billion in projected costs over the course of FY2008 to FY2010, and early results indicate that hospitals continue to reduce costs in FY2011.

Like our legislators, Massachusetts hospitals support reforming the Commonwealth's healthcare delivery and payment systems and moving away from the dominant "fee for service" payment models. The Massachusetts healthcare market is already moving ahead with voluntary payment reform efforts, and we're seeing some strong and positive results. We look forward to continued collaboration with policy makers to achieve meaningful and sustainable healthcare reform, while at the same time we recognize that progress is already being made.

The challenge of maintaining what works well in our system while reforming what doesn't work well can only be achieved if we all work together. Why? The reason is simple even if the answer isn't: there isn't a single culprit. We all contribute to the problem, we all suffer from failure, and we can all gain from success. Employers, providers, government, insurers, and consumers working together is the answer.

As we grapple with the prospect of national default over the question of expanding the US debt ceiling, Massachusetts Taxpayers Foundation President Michael Widmer's op-ed in this weekend's Boston Globe offers a clear message about additional dangers closer to home. Specifically he calls on state lawmakers not to rush into additional regulations and cutbacks for the healthcare community as part of the ongoing effort to curb costs.

As Mike very eloquently points out, "leaders must be careful to recognize that a combination of market pressures and their own recent legislative accomplishments have begun to bear fruit." He is absolutely right. Massachusetts hospitals have reduced their anticipated healthcare cost increases by $3.1 billion during 2009 and 2010 in response to both market forces and existing state laws. Yet despite these efforts, our hospitals continue to be challenged by ongoing government underpayment for care provided through Medicare and Medicaid, and by increased administrative burdens the state Medicaid program now places on healthcare providers.

Continued progress in healthcare payment and delivery reform is highly dependent on hospitals' ability to invest in resources like workforce and health information technology. With one in six Massachusetts residents employed in healthcare, and a combination of current cost-saving measures and continued government underpayment already resulting in layoffs at hospitals across the Commonwealth, now is not the time to be piling on additional restrictions.

Cautioning the state shouldn't be confused with defending the status quo. The status quo is fading fast. That is good news and paves the way for new opportunities. Change is happening fast. And government has helped stimulate that change, but it shouldn't now overreach. While government has a legitimate interest in both the delivery and cost of care, there are limits to what government can do without stifling the ability of the private market to innovate and adapt to change quickly and efficiently. It's both gratifying and reassuring that someone from outside the healthcare community is so perceptive about the potentially devastating impact of heavy-handed rate regulation and funding cuts on our hospitals and healthcare systems.  The Patrick administration, legislators and other healthcare stakeholders should heed Mike Widmer's wise counsel and refrain from harming the healthcare sector, which adds so much to the quality of life in Massachusetts by providing great healthcare and rewarding jobs today while collaborating to grow a vibrant economy tomorrow.

The Division of Health Care Finance and Policy (DHCFP) has contributed to the public dialogue on reforming the healthcare system by aggregating and reporting a great deal of data in its two most recent reports, which deal with health insurance premium trends and price variation among healthcare providers. The Division clearly exerted a great deal of time and effort to produce these reports and I look forward to a fully examining them along with the MHA staff. 

But there are significant issues with some of the conclusions being drawn from these reports. No one, particularly hospitals, is arguing against the urgent need to do something about escalating healthcare premiums. But I am deeply concerned that a well-intentioned effort to "do something" about this problem could lead to over-simplification of this extremely complicated situation and result in innovation-killing restrictions on hospitals and other healthcare providers.

The Governor often cautions against the notion that the complexity of the healthcare system should stop leaders from taking action. He makes a fair point. But it's equally true that it would be a grave mistake to ignore or underestimate what is in reality an amazingly complex system. Concern with complexity leads to inaction, while underestimating it leads to wrong action.  The correct path runs between the two poles and the dramatic changes and improvements that hospitals and others are undertaking across the healthcare system proves the point.

Although the DHCFP reports use the most recently available data, it's important to note that this information may not reflect hospitals' current reality. The report about provider payments is also based on just 32% of private insurance inpatient payments to hospitals. This use of potentially outdated information and reliance on such a small subset of payments places limitations on what conclusions can be drawn. Simply put, some of the most controversial issues raised in the reports will actually require additional data and analysis to validate or disprove them.

The report on healthcare price variation also aims to shed light on the consequences of the state’s chronic underpayment to hospitals for the cost of caring for patients in public programs such as MassHealth, but it unfortunately misses the mark. Neither providers nor insurers have stated that government underpayment is the sole driver of escalating premiums, only that it is a significant contributor.

The Division's report also inaccurately states that there is no evidence  that higher private payer prices are needed to compensate for losses incurred by servicing Medicaid patients. The Division comes to this false conclusion through its finding that hospitals with the largest share of public payer revenue do not have the highest private sector payments. Each hospital in the commonwealth is different, and unfortunately many of our hospitals that provide care to large numbers of patients covered under public programs do not have the ability to shift the government's underpayment burdens to the private sector due to their market circumstances, such as having a very small proportion of private sector patients. Many hospitals are forced to make do with these losses and this affects hospital employment, facility investment, and services.  Many other hospitals have greater opportunities to shift a portion of the burden to private insurance payers, which results in a significant impact upon private premiums.

Furthermore, the report's Medicaid analysis is based on fiscal year 2009 payment rates. While those rates reflect the first year of Medicaid rate cuts implemented by the Patrick administration, more followed in fiscal years 2010 and 2011.  And still more cuts are planned for fiscal year 2012.  Hospitals also incur additional financial losses related to care for low-income patients due to significant funding shortfalls in the commonwealth's Health Safety Net program.  Hospitals alone are responsible for paying for the shortfall, which totaled $70 million in fiscal year 2010 and which we estimate will approach $120 million in fiscal year 2011.

The Division's report on insurance premium trends does point out that medical claim increases are declining, which should have a positive impact on the price of premiums. This trend was substantiated by a report that MHA produced last year that demonstrated hospitals' projected expense trend for FY'09 and FY'10 was "bent" by approximately $3.1 billion. [Our report also noted that at the same time that hospitals were pulling costs out of the system, payments to hospitals for services in those two years were more than $2.4 billion lower than they would have been had earlier cost trends continued.] 

MHA and its members encourage informing the public about the about the cost of providing high quality care to Massachusetts patients. But just as there is no single "silver bullet" to conquer costs, neither is there one member of the healthcare community that is single-handedly responsible for causing costs to increase. All stakeholders - hospitals, other healthcare providers, insurers, the business sector, consumers and government -play an important role in mitigating the costs of healthcare. MHA will continue to work with the Patrick Administration, state legislators and other healthcare leaders to take on these difficult issues.

One day before Boston Mayor Tom Menino announced his executive order prohibiting the sale, advertisement and promotion of sugary drinks on city-owned property, Carney Hospital President, Bill Walczak, implemented a ban on sugar-sweetened drinks being sold or otherwise provided on the hospital's grounds. Bill then joined the Mayor and other leading health and nutrition experts at a press conference over the weekend announcing the expanded municipal ban (sugary drinks and unhealthy snacks were removed from Boston Public School vending machines in 2009). Carney is believed to be the first hospital in the city to prohibit sugary drinks, and it is certainly one of Boston's first big employers to take such a strong stand in the battle against obesity. Once again, Massachusetts hospitals are leading the way as stewards of the public health (pun intended). Bravo!

Recent research has shown that beverages now make up a significant portion of people's overall calorie intake, and that soda, energy drinks and sports drinks are major sources of added sugar in American diets. The added calorie intake can result in weight gain, which in turn can cause health problems like high blood pressure, diabetes and heart disease.

Mayor Menino's executive order sets science-based standards for what constitutes "healthy" drinks, and gives Boston city departments six months to clean up their nutritional act using a stoplight-based system. The city will encourage consumption of  so-called "green" beverages such as bottled water, unsweetened tea and low-fat milk; and "yellow"  drinks such as diet sodas and other diet beverages, 100 percent juices and flavored or sweetened milk may continue to be sold. "Red" beverages - including non-diet soda, pre-sweetened iced tea, dessert-like cold coffee beverages, sports and energy drinks, and juice drinks with added sugar - are being phased out entirely.

At MHA, we also take health and nutrition very seriously. We supported Governor Patrick's proposal last year to lift the sales tax exemption on candy and soda and funnel the extra revenue into health programs. While that particular effort has not been successful (yet!), as the leading voice for hospitals throughout the commonwealth, MHA employees know it's important for us to "walk the talk" on this important issue.

That's why MHA developed an initiative called HEALING, which promotes healthy eating, active living and a greener work environment. Our HEALING program sponsors health-related lectures, screenings and cooking demonstrations, and supports a wide variety of healthy options - including a healthy snacks honor bar and a relaxation room. Just recently MHA was acknowledged for our efforts when we were named one of the state's healthiest employers in the small business category by the Boston Business Journal.

So you can see that MHA is passionate about this issue - As I am personally. I have to admit I’m forever toting a Dunkin' Donuts unsweetened iced tea with lots of lemon and no artificial sweeteners. So I walk and "drink" the talk! I look forward to the day when sugary drinks are banned from all state and local government locations, not just our public schools. Meanwhile, three cheers for the City of Boston and for the health-conscious hospitals of Massachusetts for doing their part - and then some - to promote our communities' public health.

HOSPITALS are working continuously to innovate, slow the growth of healthcare costs, and improve patient care. In addition, they're implementing new care delivery strategies to make sure the care they provide is better coordinated and more efficient.

But hospitals are also encountering obstacles as they work to do their part to change the healthcare delivery system for the better. As some of the state's largest employers in this fragile economy, hospitals face the double pressures of escalating wage and benefit requirements on one extreme and continued government underpayment for the care they provide on the other. Hospitals are trying to balance the many demands on their limited resources - both human and economic - in ways that are both creative and allow for the effective continuation of their life-saving missions.

In light of these challenges, it is disappointing and disturbing to learn that the Massachusetts Nurses Association was reportedly planning a multi-hospital strike for Good Friday, April 22.

Such an action would be disruptive to providing optimal care to patients. While the nurses association now denies making a concerted effort to conduct same-day strikes at four Massachusetts hospitals and a facility in Maine, documents left by one of its members in a meeting room at St. Vincent Hospital in Worcester have been turned over to the state Department of Public Health and Executive Office of Labor and Workforce Development. Whether this reported strike action was an attempt to influence contract negotiations, mandatory nurse staffing legislation, or both isn't clear. But it's clearly the wrong thing to do for patients, other hospital workers, and the local communities involved.

We all need to work together to maintain universal access to quality healthcare in Massachusetts, and to make that care more affordable. For their part, hospitals are becoming more efficient while simultaneously continuing to improve patient outcomes. Measuring outcomes is the primary method to examine hospital performance - and the efforts of RNs are at the core of this process; yet it would be a serious mistake to undervalue or dismiss the contributions of other key members of the care team such as nursing assistants, technicians, patient sitters (who monitor patients at risk of falls and help them enter and exit beds, among other duties), pharmacists, respiratory therapists, physical therapists, and others who round out the care process. It still takes a team to care for patients. And the team's performance as a whole should be taken into account.

The union wants fixed and inflexible staffing ratios for nurses. But clearly there is no "one size fits all" method for achieving high quality, safe patient care, nor should there be. Especially during this time of dramatic, fundamental change in healthcare, it's time to think - and act - outside of the box, while keeping patient safety at the forefront.

Shackling hospitals with cookie-cutter methods for delivering care stifles innovation. It ignores the needs of individual patients. And it doesn't acknowledge our nurses' individual levels of expertise and experience. Nurses need to be treated fairly; likewise, nurse managers need the flexibility to use all of the resources at their disposal - including assistive personnel, RNs with different education and skill levels, even advanced technology - to ensure and improve the care hospitals provide. Hospitals also need to remain fiscally viable to fulfill their care-giving missions. None of these aims can be accomplished through acrimony, threats, or efforts to impose a restrictive mandate across hospitals with very different settings and diverse patient needs.

By pursuing innovative approaches to care delivery and quality improvement, hospitals can not only do right by their patients, they can also maintain a supportive work environment while providing good jobs with good pay and benefits, whether it is for a physician, a nurse, an administrative assistant, or a groundskeeper. Those jobs, in turn, will allow hospitals and their workforces to contribute to the economy in many ways. That helps everyone.