Thursday, September 25, 2014

Is the Pressure Ulcer Problem Solved?


We have discussed here earlier the fact that the former CEO of Kaiser Permanente, George C. Halvorson, in his book Don't let Health Care Bankrupt America, points out that pressure sores can be eliminated when hospitals have the right financial incentives.  "Cash flow has an incredibly powerful impact on the delivery of care.  The specific ways that we channel the flow of cash to caregivers in this country dictates almost all of the care that is delivered by those caregivers."

He points out that most hospitals are paid by an insurance company on a fee schedule for each service performed, so that services for pressure ulcer treatment improve cash flow.  But in a system such as Kaiser Permanente, where the hospital is integrated with the insurance company so that an upfront payment is made for the care of each patient,  the expenses of pressure ulcer treatment subtract directly from hospital profit.

Kaiser, in its over 30 hospitals, has reduced pressure ulcer incidence to under one percent, and many of its hospitals have reported no ulcers in several years.  The IHI has a list of a dozen mentor hospitals that have achieved one percent or lower incidence rates.  And a number of hospitals that have virtually eliminated hospital-caused pressure ulcers are described on the webpage of the National Decubitus Foundation (www.endbedsores.org).

It has been reported that there is now a trend toward a Kaiser-like payment model that is "moving quickly like a wave on a beach".  This week the New York Times reported on a new health system that may represent the most important manifestation of this trend to date:

"In a partnership that appears to be the first of its kind, Anthem Blue Cross, a large California health insurance company, is teaming up with seven fiercely competitive hospital groups to create a new health system in the Los Angeles area. The partnership includes such well-known medical centers as UCLA Health and Cedars-Sinai.

"Anthem and the hospital groups plan to announce on Wednesday the formation of a joint venture whose aim is to provide the level of coordinated, high-quality and efficient care that is now associated with only a handful of integrated health systems like Kaiser Permanente in California, Intermountain Healthcare in Utah and Geisinger Health System in Pennsylvania.

"The venture comes at a time of sweeping change in health care, set in motion by the federal Affordable Care Act and intense pressure to reduce the cost of care. Many hospitals are responding by merging and buying doctor's practices, while some are beginning to offer their own health plans for the first time.

"The plan represents a potential alternative in California to Kaiser, popular in the state and a pioneer in managing patient care through sophisticated electronic health records. I think its got the potential to operate very much the same way as Kaiser does said Ms. Boynton, who said many public employees now choose Kaiser.

"Joseph Swedish, the chief executive of WellPoint, the large commercial insurer that owns Anthem and other Blue Cross plans, says the venture is a result of the demand by employers that insurers and providers work more closely on finding better ways of delivering care. This integrated approach I would call game-changing in the Los Angeles marketplace, he said.

"While WellPoint and other insurers are experimenting with alternatives to the current practice of paying doctors and hospitals based on the volume of services they provide, hospitals in the joint venture have agreed to provide care at or below their cost and will share in all of the financial results.
The hospitals must meet certain quality standards to ensure that they are not stinting on care. But Pam Kehaly, a senior executive for Anthem, said the venture was expected to produce significant savings and profit by reducing unnecessary tests and unneeded hospital and emergency room admissions."

Clearly we know how to prevent pressure ulcers when the financial incentives are there.  We must now concentrate on seeing to it that the trend toward integrated healthcare systems continues.

Wednesday, July 16, 2014

Promising Developments


Several news reports have been published in the past few weeks indicating that both insurers and hospitals are searching for new ways to provide insurance payments. As has been discussed earlier, reimbursing for each procedure involved in treating pressure ulcers does not work to prevent ulcers; in fact, this method of payment only adds to the hospital's cash flow. But paying upfront for prevention provides a strong incentive for hospitals to avoid all of the additional expenses incurred when they allow a patient to develop a pressure ulcer. This has been shown to be the reason that Kaiser Permanente hospitals have been able to reduce their rate of pressure ulcer incidence to virtually zero.

We will include several of these promising articles in the upcoming NDF Summer 2014
issue of The Ugly Secret.

Thursday, January 30, 2014

IS THIS WHY HOSPITALS WON'T STOP?

The name of this blog is "Why won't hospitals stop causing bedsores?". Ever since we submitted our paper in 2006 showing how a handful of hospitals had reduced bedsore incidence to near zero, we have had to wonder why all hospitals did not follow their example.

A book has just been published that explains why this may never happen unless the method of hospital compensation by insurance companies changes dramatically.  George C. Halvorson, former CEO of Kaiser Permanente, is the author of "Don't Let Healthcare Bankrupt America."  Mr. Halvorson writes:

"Pressure ulcers are a perfect example of the perverse way we pay for care today.  Seven percent of the hospital patients, on average, end up with a pressure ulcer in American hospitals.  The best hospital care sites in this country now have less than one percent of their patients getting pressure ulcers.  The very worst care sites have upwards of ten percent or their patients getting pressure ulcers.

"Ten percent ought to be regarded as an unforgivable number. Seven percent should also not be an acceptable percentage by hospital care teams. Some of the very best hospital care sites have managed to go for more than a year without one single stage-two or higher pressure ulcer. Not one.  That is amazing patient-centered, patient-focused care.

"By contrast--a lot less money is spent at the best sites, and more patients survive at those best sites....those best hospitals also make a lot less money from each ulcer patient and from pressure ulcers overall. Based on the way we buy care today in this country, the reward for doing well is to get paid less.

"...the payers who use the insurance fee schedules to define the care they pay for will cough up an average of $40,000 in fees to the care site for each pressure ulcer patient....Doing all the things needed to keep those ulcers from happening are not accepted as billable sources by the fee schedule that is usually used to pay for approved care -- so very few fee-based care sites do that preventive work....There is also no fee to have the highest risk patients in beds that have special liners.

"The care priorities and the care delivery approaches that result from a flat payment approach for a package of care can be very different than the priorities that are a fact of life for a fee-based piecework payment business unit.

"Kaiser Permanente is one of those prepaid care teams that sells care by the package and not by the piece.  With three dozen hospitals, 550 medical care sites, 180,000 caregivers, and 9 million members, Kaiser Permanente is paid a flat fee every month for each of the 9 million members, and uses that money to provide the care needed by the 9 million people....Being freed from the tyranny and structure of a piecework cash model allows the care teams to focus on the patients.

"The pressure ulcer work at Kaiser Permanente has gotten continuously better. the care model of being paid by the package rewards continuous improvement.  With that payment model, the ulcer level has dropped from 3 percent to 2 percent of patients and now it averages less than 1 percent.....Some Kaiser Permanente hospitals have not had one single pressure ulcer for more than a year."

"Patients who get these ulcers are often in great pain.  Some are damaged for life.  Some are badly disfigured.  Some die.  Getting a pressure ulcer is not a good thing for a hospital patient.

"So how does the business model we use now to pay for care deal with these major differences in performance for care sites relative to pressure ulcers?

"Very badly or very well - depending on whether you are paying for those ulcers or charging fees to treat those ulcers.

"Care actually costs a lot more at the worst care sites.  Those sites get paid more money because they deliver poor care.  A lot more cash flows to the very worst care sites. Patients are individually damaged at those worst care site and the way we buy care today, the sad truth is that the cash flow for those poorly performing care sites increases significantly as their care deteriorates."

Are our efforts to inform hospitals how the best performing hospitals are eliminating bedsores all in vain until we are able to change the business model?  Is the profit motive so strong that hospitals continue causing pressure ulcers that they know how to eliminate?

Wednesday, September 25, 2013

Flap Fails to Close

A recent press release from JusticeNews Flash.com (Clinitron Bed Management For Flap Patients Is The Standard Of Care, 2013-06-19) brought back angry memories of my mother's hospitalization and death.  For exactly the reasons stated in the press release quoted below,  the hospital and the plastic surgeon refused to pay to rent the air fluidized bed that is the standard of care for flap patients.  Her surgery failed three times, and only one night in all that time was she allowed to have the Clinitron bed.

"Patients, providers, and families expend great effort in attempting closure of Grade 3 and Grade 4 decubitus ulcers. Patients die, become progressively debilitated, suffer a loss independence, and become progressively depressed directly because of decubitus ulcers. All necessary and appropriate care must be utilized for these patients, and that would include the use of clinitron beds after flap closure. Cost cutting and the rationing of state of the art medical care should not compromise this unfortunate population and all attempts must be made to obtain a successful flap outcome. The prospect of using less expensive beds that have inferior pressure relieving capabilities is a repulsive idea that is the result of unjustified rationing of medical services brought on by aggressive hospital administers trying to save cost and the expense of patients who suffer from chronically disabling conditions."

Monday, July 1, 2013

Take Action on AHRQ Findings


AHRQ Findings Match NDF
Issues Major Report Confirming NDF Protocol
 
Now that we have the support of the AHRQ, the NDF must take steps to make those results known.  We will write each of the pressure ulcer experts named in the AHRQ report as having contributed to the effort, urging each of them to work at their state level to require that hospitals make the necessary investment in advanced support surfaces. 
 
The Agency for Healthcare Research and Quality (AHRQ) of the Dept of Health and Human Services is charged with providing evidence-based information so that providers and consumers can make the best possible clinical decisions.  The AHRQ has just released a comprehensive 358 page report (Comparative Effectiveness Review Number 87) reviewing and summarizing all known information bearing on pressure ulcer prevention. The report is entitled "Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness".

This report comes to precisely the same conclusion that the NDF did back in its July 2008 study, "Reducing Pressure Ulcer Incidence through Braden Scale Risk Assessment and Support Surface Use", Advances in Skin & Wound Care, p 330-334. This study forms the basis for the NDF Prevention Protocol, a procedure adopted by many hospitals to effectively drive their pressure ulcer incidence to zero. The protocol consists simply of two elements:
 
1. Assess the pressure ulcer risk for every patient at admission using the Braden Scale.

2. Immediately place each at-risk patient on a pressure-relieving surface proven to have been effective in pressure ulcer prevention.
 
As the following excerpts from the conclusions of the AHRQ study illustrate, the AHRQ has also come to the conclusion that only risk assessment followed by support surface use have been demonstrated to be effective pressure ulcer prevention tools:
 
"Studies of diagnostic accuracy found that commonly used risk-assessment instruments (such as the Braden, Norton, and Waterlow scales) can identify patients at increased risk for ulcers, with no clear difference among instruments in diagnostic accuracy"
 
"In higher risk populations, good- and fair-quality randomized trials consistently found that more advanced static mattresses and overlays were associated with lower risk of pressure ulcers compared with standard mattresses (RR range, 0.20 to 0.60), with no clear differences between different advanced static support surfaces."
 
The AHRQ was unable to find any other factor that could be shown to be effective in pressure ulcer prevention:
 
"Evidence on other preventive interventions (nutritional supplementation; repositioning; pads and dressings; lotions, creams, and cleansers; and intraoperative warming therapy for patients ES-18 undergoing surgery) was sparse and insufficient to reach reliable conclusions.....".  

Thursday, May 30, 2013

AHRQ Finds NDF Was Right

Back on October 12, 2013, we wrote the Agency for Healthcare Research and Quality (AHRQ) of the US Dept of Health and Human Services to comment on their publication,  Preventing Pressure Ulcers in Hospitals - A Toolkit for Improving Quality of Care.  The AHRQ Toolkit included a wide variety of activities, including turning, repositioning, nutrituional aupplements, pads and dressings, lotions and cleansers, etc.

We wrote that their toolkit was unnecessarily complicated and detailed, and urged the adoption instead of the NDF Prevention Protocol:

               1. Assess the pressure ulcer risk for every patient at admission using the Braden Scale.

               2. Immediately place each at-risk patient on a pressure-relieving surface proven to have   been effective in pressure ulcer production.
                            
In reply the AHRQ wrote that "The hospital is given the option to customize its prevention strategy based on the tools provided".  (This has been the case forever with no discernable improvement - ed.)

But this month (May 2013) the AHRQ has published its 400+ page comprehensive Comparative Effectiveness Review number 87, Pressure Ulcer Risk Assessment and Prevention: Comparitive Effectiveness.  In this exhaustive report the AHRQ was able to make only three definitive statements:

1." ...commonly used risk assessment instruments (such as the Braden, Norton, and Waterlow Scales) can help identify patients at increased risk for ulcers.."

2." ....randomized trials consistently found that more advanced static support surfaces were associated with lower risk of pressure ulcers compared with standard mattresses in higher risk patients with no clear differences among different advanced static support surfaces."

3. "Evidence on effectivenes of other preventive interventions (nutritional supplementation; repositioning; pads and dressings; lotions, creams, and clensers; ...) compared with stand care was sparse and insufficient to reach reliable conclusions."

Evidently the AHRQ has convinced itself that the NDF Prevention Protocol is the only thing that makes sense.


Wednesday, May 8, 2013

How Widespread is this Despicable Practice?

The March 2013 issue of Advances in Skin & Wound Care contains an article, "Construct Validity of the Moisture Subscale of the Braden Scale for Predicting Pressure Sore Risk"   by Omolayo, T et al.  One of the factors contributing to moisture in the Braden Scale is incontinence.

"The authors were surprised to find incontinence briefs in use among participants who are reported to be continent.  It appears briefs are used when residents cannot reach the commode in a timely manner or when nursing assistants are unable to respond promptly to resident calls. Briefs become a toileting alternative. This economy of effort is not consistent with the goals of mobilizing residents to prevent muscle weakness, decrease incontinence, and prevent PrU's.  Toileting deserves more attention.  If residents receiving rehabilitation services are encouraged to use briefs instead of walking or being assisted to the commode, it is possible that mobilization and bladder training controls are not being met. This may delay rehabilitation or result in longer nursing facility care.  There is evidence that bladder training and mobilization can be improved with regular toileting, and this should be a goal of care.  One study of culture of care in two nursing facilities demonstrated that, even in a setting with a strong culture of care, a commitment to continence care and incontinence prevention was not fully embraced."

Evidently many facilities are using diapers to replace nursing assistants, thereby saving money and increasing profits.  This is exactly what happened to our mother in the hospital, leading to her pressure ulcers and her death. This despicable practice must stop.  An investigation is needed  to see how widespread this practice is.