Voices in Healthcare

Ben Franklin's old idiom "an ounce of prevention is worth a pound of cure" was actually fire-fighting advice, but here in Massachusetts we can avoid a fiscal inferno later if we take precautionary action now to protect an expected influx of Medicaid funding to the state.

The Patrick administration estimates Massachusetts will add another 220,000 Medicaid enrollees in 2014, and Congress provided support for these new enrollees in the form of increased Medicaid matching funds. But the funding is currently slated for the state's General Fund, where it could be spent for unintended purposes down the road.

My op-ed that appeared in Saturday’s Boston Globe highlights a simple yet vitally important opportunity we should take – right now – to ensure that Massachusetts is both fiscally and socially responsible with the additional Medicaid funding that is headed our way: We need to put those funds in a separate, targeted account designated solely to paying for healthcare for the lower-income population. That's what Congress intended, and it's the right thing to do.

Such a trust fund will also ensure transparency and accountability on the use of the new Medicaid funding for years to come. If those dollars simply disappear into the state's General Fund and are not used to support Medicaid and other low-income healthcare programs, we're inviting a funding crisis down the road. Such a crisis is 100 percent avoidable if we take this common sense step and set the funds apart now – An ounce of prevention.

The Medicaid trust fund is an idea that's easy to overlook in all the frenzy of state budget negotiations and work to align Massachusetts' ahead-of-the-curve healthcare reform with the federal Affordable Care Act. But it's an opportunity and a safeguard we absolutely cannot afford to miss.

Since the senseless attack on the Boston Marathon occurred on April 15, it has been a truly extraordinary time for Massachusetts and for our state's hospitals in particular. While so much has been said already from the president to our elected officials, about the stellar ways that our state's healthcare providers rose to meet the challenges of this horrific event, I wanted to share the overview of our hospital community's extraordinary response to this tragedy that appeared in MHA's Monday Report. The article truly captures some of the outstanding examples of our hospitals' outstanding work and the exceptional caliber of those healthcare professionals who showed us their best on the darkest of days. The text of the article is posted below:

UNPARALLED CARE IN THE FACE OF TRAGEDY

The horrible events that occurred on Patriots Day, April 15, 2013, during the annual Boston Marathon caused incalculable pain and suffering. But the loss of life and devastating injuries could have been worse. Because of the quick action of first-responders, the unselfish actions of bystanders, and the fact that the race was staffed by, and close to, some of the best medical talent on the globe many of the injured were able to receive immediate, lifesaving, coordinated care that reduced what could have been a more staggering fatality toll.

The Massachusetts healthcare system – from on-site caregivers who ran towards the blasts to help the injured, to the EMS officials who seamlessly triaged patients and directed ambulances, to the world-class hospitals staffed by remarkable surgeons, nurses, and others – all performed excellently, garnering the admiration and gratitude of the nation and world.

"… WE WILL CHOOSE TO SAVE AND TO COMFORT AND TO HEAL"

After speaking at an interfaith service at the Cathedral of the Holy Cross in Boston on Thursday, President Barack Obama visited Massachusetts General Hospital (shown below) where he met with patients injured in Monday's blasts and the hospital staff that is caring for them. First Lady Michelle Obama visited Brigham and Women's Hospital.

At the interfaith service, Obama said of Boston, "Year after year, you welcome the greatest talents in the arts and science, research -- you welcome them to your concert halls and your hospitals and your laboratories to exchange ideas and insights that draw this world together … You've shown us, Boston, that in the face of evil, Americans will lift up what's good. In the face of cruelty, we will choose compassion. In the face of those who would visit death upon innocents, we will choose to save and to comfort and to heal. We'll choose friendship. We'll choose love."

Photo: Pete Souza, White House

20 HOSPITALS; 219 PATIENTS

Following the explosions, the Boston Medical Intelligence Center was set up as the lead point of contact. It coordinated information sharing on family unification, and was the lead for assessing continuing needs, and available resources for medical-surgical and mental health services.

Hospitals were requested to provide information about patients to the Department of Public Health's Department Operations Center. As of Thursday afternoon, 219 patients associated with the blast were treated at the following 20 hospitals and one health center:

Beth Israel Deaconess Medical Center; Beth Israel Deaconess Hospital – Needham; Boston Medical Center; Brigham and Women's Hospital; Cambridge Health Alliance; Carney Hospital; Boston Children's Hospital; Emerson Hospital; Faulkner Hospital; Hallmark Health; Massachusetts General Hospital; Massachusetts Eye and Ear Infirmary; MetroWest Medical Center; Milford Regional Medical Center; Mount Auburn Hospital; Neponset Health Center; North Shore Medical Center; South Shore Hospital; St. Elizabeth's Hospital; Tufts Medical Center; and Winchester Hospital.

WHY WAS THE RESPONSE SO EFFECTIVE?

It wasn't luck that the medical response worked so effectively. Rather it was the result of a Massachusetts emergency response system that had planned, practiced, adapted, and evolved over the years, combined with the actions of so many people who performed extraordinarily under such dire circumstance.

On Monday, the large number of Emergency Medical Service (EMS) personnel on site was of great importance as they were able to triage and coordinate patient care quickly. The communications system that was in place between hospitals, the Central Medical Emergency Direction (CMED) Center, and Regional EMS – including use of the statewide WebEOC system that is managed by the Massachusetts Department of Public Health's Emergency Preparedness Bureau – all helped everyone communicate needs and resources. (WebEOC is a crisis information management system that provides real-time information sharing. MHA learned that all providers went into WebEOC within minutes to update important data such as bed and staffing availability; this was the central and most effective method for providers to know what was expected, what might be coming and where to turn for assistance.)

The explosion occurred in close proximity to many hospitals, including five Level 1 Trauma Centers, meaning they have the expertise to treat just about any injury that comes through their doors. These hospitals also have specially trained staff that helped write the national guidance and protocols on mass casualty, disaster planning, and trauma-level services.

An important factor that helped with the coordination was the elimination of ambulance diversions within Massachusetts a few years ago. With this change, hospitals learned how to coordinate patient-care needs hospital wide when their emergency departments were full with emergent and urgent situations. During Marathon Monday's tragedy, hospitals were able to coordinate/change operations quickly to meet patient need; many hospitals received 10 to 20 or more mass casualties in under an hour.

And because hospitals were well equipped with equipment and medical supplies they were able to provide emergency and trauma level services in a timely manner to all patients that came into their EDs.

Preparedness also played a key role. All hospitals have conducted city-wide and whole-hospital drills to help them develop internal procedures for how to respond to a mass casualty. As has happened in other serious situations, off-duty hospital staff (physicians, nurses, and ancillary workers) immediately left their homes and went to their hospitals to provide help to their on-duty colleagues. Staff also coordinated internally to ensure that there were enough caregivers to handle the patient flow. Hospitals checked availability and pulled staff from various departments or other local providers to help shifts as needed. It also became clear that numerous doctors, nurses and other medical personnel at Massachusetts hospitals had battlefield experience from serving overseas or had experience treating U.S. soldiers returning from war, which assisted them in dealing with bomb-related injuries.

The state, through the "HHAN" emergency communication network and DPH, provided guidance, and MHA was in constant communication with its membership.

All in all, the system worked when it was called upon to meet an unprecedented mass casualty situation. Governor Deval Patrick, in a moving speech before an interfaith gathering on Thursday, spoke of the many things for which he was grateful in the aftermath of the explosions, saying, "I’m thankful for the medical professionals -- from the doctors and trauma nurses to the housekeeping staff, to the surgeon who finished the marathon and kept on running to his operating room -- all of whom performed at their very best." 

MHA's and COBTH's STATEMENT

MHA President & CEO Lynn Nicholas, FACHE, and the Executive Director of the Conference of Boston Teaching Hospitals John Erwin released the following statement following the Boston Marathon tragedy:

On behalf of our hospital community, MHA and COBTH would like to express our heartfelt sorrow and sympathy to the victims and families of yesterday's tragic events at the Boston Marathon. Our thoughts are with those families who lost loved ones, those who were injured and those indirectly affected. We want to commend the heroic efforts of hospitals, first responders, and the local, state and federal agencies that collaborated to ensure that the injured received care in the immediate aftermath of the event. Those on the frontline helped save lives, many without regard to their own personal safety.

In particular, we want to express our appreciation and admiration for the professional and dedicated efforts of all hospitals and their staff that worked to care for these patients under extraordinary conditions. Even as the care for victims who were gravely injured continues, hospitals are working together and collectively with the state to identify additional resources that can be extended to support the broader community both at this time and in the coming weeks

MENTAL HEALTH NEEDS NOT FORGOTTEN

Even as lives were being saved on Monday through timely triage and surgery, the mental healthcare system was moving into high gear. It became apparent early on that the patients, families, and public affected, as well as caregivers – especially first responders – grappling with unspeakable horror could be emotionally scarred by the experience. The U.S. Department of Health and Human Services immediately deployed 21 mental health professionals to assist throughout Boston. In a conference call between hospitals and state officials on Tuesday, the Boston Medical Intelligence Center requested that hospitals and other healthcare providers quickly provide not only the mental health resources they were able to offer but also the services that may be required for patients and staff. The Massachusetts Department of Mental Health attempted to coordinate mental healthcare resources from around the state and on Thursday posted these state and federal resources on its website.

POST ACUTES OFFER HELP

In the hours and days following the bombing, MHA received numerous calls from the post-acute community – long-term acute care hospitals, inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies. The discussions focused on one question: How can we help? During the crisis, the post acutes offered to take patients to relieve any congestion among the acute care hospitals. And as the extent of the injuries became clear – many amputations requiring extensive rehabilitation – the post acutes knew that their expertise would be required in the future.

BOSTON BLOOD SUPPLIES OK FOR NOW; BUT GIVE LATER

As the details of the tragedy became apparent, people from around the commonwealth obviously thought that the most important and appropriate offering they could make to those fighting traumatic injuries was the gift of blood. Fortunately, Massachusetts hospitals were well stocked during the tragedy and actually had to turn away donors. But blood donations will always be needed; it's just a matter of giving at the right time. The American Red Cross urged people to call 1-800-RED CROSS or click here to schedule an appointment to give blood in the days and weeks ahead.

THE ONE FUND

Massachusetts Governor Deval Patrick and Boston Mayor Tom Menino have announced the formation of The One Fund Boston, Inc. to help the people most affected by the tragic events that occurred in Boston on April 15, 2013. Find out more here.

I'm delighted that MHA has once again been named one of the Boston area’s healthiest small companies by the Boston Business Journal (BBJ). The association was honored as a runner-up finalist yesterday as part of the BBJ’s Healthiest Employers program, which recognizes area companies in small, medium, and large business categories that have gone above and beyond in promoting wellness. MHA won the BBJ's top honor in 2011, and was named one of Boston’s runner-up healthiest employers in 2012 as well.

Congratulations also to two of MHA’s two member hospitals – Lowell General Hospital and Southcoast Hospitals Group – that were finalists in the large employer group, and to EMC Corp., which has representation on MHA's board of directors and was first runner-up in that category.

All of our organizations are looking to support healthy lifestyle choices and improved health, both on and off the job. We learn from others, share best practices, and actively promote employee and public health as part of our work culture.

So I'm afraid I must disagree with Ezekiel Emanuel et. al.'s piece in this week's New England Journal of Medicine that accompanies the Journal's excellent Perspective article on the controversies that surround the issue of not hiring smokers. Emanuel and his colleagues contend that employers – especially those of us in the healthcare sector – should refrain from imposing hiring bans on tobacco users because we don't refuse to treat patients whose personal lifestyle choices may have landed them in the hospital.

I fall very firmly in the camp of the Perspective authors David A. Asch, M.D., M.B.A., Ralph W. Muller, M.A., and Kevin G. Volpp, M.D., Ph.D., who conclude that "given the threats that tobacco presents to our communities and institutions," more direct intervention to curb tobacco use is warranted.

We have set broad cost-reduction goals for total healthcare expense in Massachusetts that require interventions and changes in consumer and patient behavior well beyond the walls of the hospital. Now more than ever, hospitals and other healthcare organizations have an opportunity and an obligation to demonstrate for the communities they serve the kinds of healthy behavior that will lead to longer life, a higher quality of life and a lower burden of healthcare expense.

MHA enacted a policy to not hire tobacco users back in January of 2011, and to date at least five of our member hospitals have also instituted policies to no longer hire tobacco users. I'm extremely proud that we have made such a bold move to promote a healthy workforce and reduce the leading preventable cause of death in the US. I hope more hospitals, health systems and businesses throughout Massachusetts and the nation follow the recommendations of Asch and colleagues, and our course.

The effort to remove protective tax exemptions from sugary beverages and candy in Massachusetts is back, and I hope 2013 is the year we get this extremely important public health initiative over the goal line.

The proposal is already garnering some well-deserved media attention on WBUR 90.9 FM and its CommonHealth blog; meanwhile, the evidence that over-consumption of sugar-sweetened beverages and candy are damaging Americans' health – especially our children's health – continues to mount. At this point, many children drink more sugar-sweetened beverages than milk, and sugar-sweetened beverages represent the largest category of daily caloric intake (7%–12%) for many demographic groups. For each extra can or glass of sugared beverage consumed per day, the likelihood of a child's becoming obese increases by 60%.

The research also shows that taxes on sugary drinks can cut consumption and reduce caloric intake, especially if consumers switch to more healthful beverages. According to the New England Journal of Medicine, one review conducted by Yale University's Rudd Center for Food Policy and Obesity suggested that for every 10% increase in price, consumption would go down by 7.8%.

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. I contend that soda and candy should not be considered "food" under this definition, should be subject to the sales tax, and revenues generated from their sale should be used to support public health efforts to improve nutrition and lower obesity rates for Massachusetts residents.

The Massachusetts Hospital Association (MHA) is a member of the Healthy People/Healthy Economy Coalition, which is continuing its call for an end to the state sales tax exemption for soft drinks and candy. Massachusetts should join the more than 40 other states that already impose sales tax on sugary drinks and candy and end what amounts to a taxpayer subsidy on such items, to support improvements to our residents' public health.

If we want to lower healthcare costs, we need to support prevention efforts along with payment and care delivery reform. The state legislature has really focused on lowering healthcare cost trends in recent years and now they can make further advances by supporting measures like this. As a commonwealth, we now promote accountable care. I think the time is ripe for an accountable health policy. The two should be aligned and removing the tax exemption on sugary beverages and candy is a sensible and important step in that direction.

An article in today's Boston Business Journal details efforts by Massachusetts state health officials to actively promote the creation of routine care clinics at retail pharmacies as a way to rein in care costs. The idea is to expand the number of walk-in clinics operated by for profit (and therefore cost-conscious) retail chains in order to decrease the number of patients going to more expensive hospital emergency departments for minor problems.

Care providers partnering with retail chains for some aspects of healthcare is a reasonably new concept, and one that fits squarely into Harvard Business School professor and innovation guru Clayton Christensen's definition of "disruptive innovation." While this strategy is concerning for some providers, if done properly, it is exactly the type of market innovation that will help to reduce the cost trend overall and ease access to care for many. Certainly coordination of care shouldn't be undermined, and so the commitment of state officials to "make sure there is strong coordination between retail clinics and primary-care doctors when providing care" is important. Providers that learn to partner with and use such resources to help manage the health of a population will benefit and the biggest winners will be consumers. 

As implementation of both federal and state healthcare payment reform legislation gets underway in earnest, the myth that Massachusetts healthcare costs are the most expensive in the country is once again making the rounds. So, even as hospitals and others who care about the healthcare system work to lower costs, it's time to set the record straight.

It's no secret that it is expensive to live to Massachusetts – the cost of necessities such as housing, utilities, transportation, and even groceries all exceed the national average and are greater here than in most other states. Massachusetts employers also pay higher salaries and wages. The evidence of higher costs for living here and doing business here is plain to see. Healthcare isn't exempt. It has to deal with those same higher costs.

In looking at healthcare costs overall, when factors such as wages and cost of living in the state are taken into account, Massachusetts costs are much closer to the national average. But most people measure health care costs by what they pay for health insurance premiums. The latest Commonwealth Fund report on health insurance cost trends shows that our family insurance premiums, after factoring in median household income, rank 46^th lowest of all the states and the District of Columbia. In other words, the average family health insurance premium in the state, as a percentage of median household income, is actually among the most affordable in the nation. This is true even after factoring in that Massachusetts has among the best health insurance benefits in the country. We should be proud to have those benefits, but we must also recognize that they do raise healthcare costs and those costs are reflected in premiums.

There is a broad, continuing commitment from hospitals and others in Massachusetts to lower healthcare costs. Providers, government, insurers, employers, and even consumers all contribute to the cost of healthcare and collectively we share a responsibility to work collaboratively to lower costs while maintaining everything in the system that we're proud of. But sometimes rhetoric gets in the way of an accurate portrayal of the cost of healthcare here. While we can and must do better, and hospitals are committed to that goal, progress can be only be made when everyone is working with an accurate and valid set of facts.

You might want to take a look at Paul Levy's blog regarding a challenge to hospital CEOs across the nation to get involved in the gun control debate, particularly in terms of assault weapons.  I could not agree with him more. As healthcare executives we should be leading the charge on many aspects of the business of health, not just those that affect hospitals directly. Furthermore, we should be doing everything we can to keep people out of our hospitals. This matter is no doubt very complex; it is a societal issue and, as Paul suggests, a public health issue as well.

I look forward to engaging the MHA Board of Trustees on this topic, particularly as Massachusetts considers its own options. But as healthcare executives, we should not wait for a "convening discussion." I hope all leaders in the hospital arena will do what they can both publicly and privately to help advance this issue in a way that safeguards the communities we serve to a better degree.

It's gratifying to see the Massachusetts Hospital Association's work on tobacco cessation gaining some traction with the commonwealth's broader business community, as this recent blog positing from Associated Industries shows. In 2010, MHA launched a voluntary initiative to encourage hospitals across the state to ban the use of tobacco anywhere on campus. The association also instituted a policy against hiring tobacco users and I'm delighted to report that now 71 percent of MHA's member hospitals are tobacco free, and at least five member hospitals have also instituted policies to no longer hire tobacco users.

Contrary to critics concerns at the time, the policy has not been a deterrent to our hiring qualified people. In fact, just the opposite effect occurred. One applicant that we declined to consider for an open position because they were a tobacco user told us MHA's policy made them want to work at the association even more, and that they respected the decision. By going tobacco free on their campuses and even further by declining to hire tobacco users, hospitals send a strong signal of commitment to combat the ill health and extraordinary cost of care associated with tobacco use. MHA is proud of its role to assist Massachusetts hospitals to voluntarily take such important steps forward.

I encourage all businesses, but most especially those in healthcare, to visit our HEALING Inside & Out: Massachusetts Tobacco-Free Hospitals website, created by MHA in cooperation with the Massachusetts Department of Public Health (DPH) to eliminate the use of all tobacco products on hospital campuses.

The online tobacco-free resources at the site include implementation how-to's, statistics, best practices, case studies, useful web links, a communications tool kit, and much more.

It's a wealth of useful information and a step in the right direction.

National events of the last few weeks surrounding the very tragic meningitis contamination within some compounded drug shipments has led to 31deaths and illnesses of hundreds of patients across the country. The subsequent investigation has so far led to the permanent closure of the New England Compounding Center and extended closure of a sister facility, Ameridose. While appropriate, the closing has also exacerbated very troubling and long standing drug shortages at hospitals across Massachusetts and nationwide. Even prior to the closing, our hospitals were deeply concerned about the possibility of prolonged and serious shortages of important medications. Now the shortages have taken a distinct turn for the worse.

While the hospital community and MHA continue to work with the Massachusetts Department of Public Health (DPH) on the situation, hospital pharmacies are facing an increasingly uphill battle. They are seeking accredited alternative suppliers from across the country and conferring with affiliates and partners for possible relief. And those hospitals with in-house medication compounding capabilities have added staff and hours in order to boost supplies of needed medications.

MHA is coordinating efforts to facilitate discussions and help identify possible ways that hospitals can develop alternative sources. But the shortages promises to become worse, not better. That is why it is essential that state and federal agencies, in a timely fashion, help identify and secure safe alternative sources for critically needed medications.