The Daily Briefing

News for Health Care Executives

Where the Medicare ACOs are, 2014 edition

February 03, 2014

On Thursday, CMS released the first results from the Medicare Shared Savings Program (MSSP), announcing the performance of the 114 organizations that joined the program in 2012.

Nearly half of the 2012 ACOs—54 out of 114—successfully reduced spending for attributed beneficiaries below their expenditure target. However, only 29 of the ACOs generated enough savings to qualify for shared savings bonuses. These top-performing ACOs earned $126 million in shared savings payments. Overall, the 2012 ACOs generated $128 million in net savings for CMS.

Major study calls into question the value of screening mammograms

Mammography does not appear to affect cancer death rates, BMJ reports

February 12, 2014

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An expansive 25-year study in the journal BMJ has found that breast cancer death rates were the same among women who underwent annual mammograms and those who did not, shedding doubt on claims that the screenings help save women's lives.

Study: Screening mammograms do not appear to change cancer death rates

For the study, one of the largest of its kind, researchers analyzed Canadian National Breast Screening Study data on 89,835 women ages 40 to 59 from six Canadian provinces.

Starting in 1980, all participants received physical breast exams each year, and half of them also received annual mammograms for five years. The researchers then monitored the woman for 25 years. (The report did not examine the use of mammograms as a diagnostic tool, which experts generally agree is valuable.)

  • With screening mammograms: The study found that 3,250 of the 44,925 women who received annual mammograms were diagnosed with breast cancer. There were 500 patient deaths from breast cancer in that group.

  • Without screening mammograms: The study found that 3,133 of the 44,910 women in the control group were diagnosed with breast cancer. There were 505 breast cancer deaths in the group.

The study notes that the death rates from all other causes also were the same among the two groups.

Overall, the researchers determined that 22% of the cancers detected by mammograms were overdiagnosed, meaning they were so slow-growing that they would have never harmed women and were treated unnecessarily. Without the screening, these women likely would have never learned they had cancer or gone through treatment, the study said.

Further, lead study author Anthony Miller, an epidemiologist at the University of Toronto's Dalla Lana School of Public Health, said overdiagnoses would have increased to about one in every three cancers if the researchers had also included a precancerous condition called ductal carcinoma in situ.

In an editorial accompanying the study, Mette Kalager—an epidemiologist and screening researcher at the University of Oslo and Harvard School of Public Health—and other experts argued that other studies that have found a benefit to screening mammograms were conducted prior to the widespread use of breast cancer drugs, such as tamoxifen, that have significantly reduced the death rate from breast cancer.

Kalager also said that many prior studies did not randomly assign participants to the intervention or control group, which is considered the gold standard in clinical trials.

What the findings mean for medicine

About 37 million mammograms are performed in the United States each year, at a cost of about $100 per mammogram, according to the New York Times. The American Cancer Society and the American College of Obstetricians and Gynecologists recommend that women receive annual mammograms starting at age 40, while the National Cancer Institute recommends that women in their 40s have the screening every one or two years.

The findings are not expected to lead to any immediate changes in mammography guidelines, and many experts "will almost certainly dispute the idea that mammograms are on balance useless, or even harmful," according to the New York Times.

However, the results provide new evidence for a growing number of experts who question the benefits of widespread screening mammography.

The American College of Radiology (ACR) immediately issued a statement arguing that the Canadian National Breast Screening Study is "deeply flawed" and "incredibly misleading." ACR said, among other things, that the research was based on "second-hand" mammogram technology that was operated by inadequately trained technicians (Kolata, New York Times, 2/11; Morin, Los Angeles Times, 2/11; Szabo, USA Today, 2/11).

The Advisory Board's take

Ingrid Lund, Imaging Performance Partnership

This study is certainly important news because mammography is such a widely used screening tool and breast cancer is the second most common cancer in the United States.

However, recent changes in the guidelines regarding the use of mammography, including the recently revised guidelines from the U.S. Preventive Services Task Force, have created a great deal of confusion among women about when they should start getting mammograms and how often. In all likelihood, these findings will only add to that confusion.

On the other hand, it's very positive that we're continuing to learn more about the pros and cons of mammography and have more data available to help individual women and their physicians make informed choices.


How Navy ships prevent norovirus outbreaks

Rigorous discipline, devotion limits disease spread

February 12, 2014

CNN's Aaron Cooper this week explained how the United States Navy—with 323,000 active duty service members housed in tight quarters—is able to prevent the spread of highly contagious infections that recently have caused havoc on commercial cruise ships.

Last month, a norovirus outbreak sickened nearly 700 passengers and crew members onboard Royal Caribbean's Explorer of the Seas. The fast-moving, highly contagious infection hit again days later on Princess Cruises' Caribbean Princess ship, causing gastrointestinal symptoms in 178 passengers and 11 crew members.

Norovirus may have sickened hundreds aboard cruise ship

A similar outbreak would devastate a Navy ship, says Capt. Jim McGovern, commanding officer of the USS Iwo Jima. "If we had a norovirus that took out 700 sailors, we obviously would be operationally ineffective, combat ineffective—but even a smaller number, a smaller outbreak of, say, 100 would devastate our operational capability," he told Cooper, adding that outbreaks of just 10 or 20 people are taken very seriously.

To prevent that from happening on deployment, the Iwo Jima's 3,200 marines and sailors are medically screened and vaccinated prior to being allowed on the vessel. "The idea is to prevent somebody from getting ill. Once you do become ill from one of these highly contagious organisms, you are really chasing it then," says Vice Adm. Matthew Nathan, who serves as Surgeon General of the Navy.

Once onboard, sailors are required to report to sickbay if they feel sick—with no exceptions. "If they are particularly stoic and don't want to come to us for whatever reason, their supervisor will make them come," says senior medical officer Sean Sullivan. If symptoms of a virus are confirmed, the sailor will be isolated to prevent the spread of infection to the rest of the ship's inhabitants.

What infectious disease can teach us about chronic care

Rigorous, daily cleaning routines also are a key part of the Navy strategy to thwart infectious diseases, including foodborne illnesses. Preventive medicine technician Aaron Ferguson inspects the ship's kitchens several times a day to ensure workers' "hands are clean, uniforms are clean, they have hairnets on properly, making sure their lines are clean, so there is not dirt buildup or anything like that which could get people sick," he says.

Nathan notes that the risk of infection is lower on a Navy ship simply by not having certain "creature comforts" that cruise ship passengers expect. "If you have a ship whose main center of gravity is social gatherings, food places, dancing areas places for libations, and gating on decks and swimming pools—all of those things that sailors wish they had, but don't have on our Navy ships—then I think it is a much more challenging environment to control the spread of a highly contagious virus" (Cooper, CNN, 2/11).


Doctor-turned-patient: I 'never before understood how much' nurses matter

A look at why physicians tend to undervalue the importance of nursing

February 12, 2014

In the latest issue of The New York Review of Books, eminent medical educator and editor Arnold Relman detailed his hospitalization and recovery from a serious accident. Despite spending six decades in medicine, Relman writes that it wasn't until he became the patient that he truly understood "how much good nursing care contributes to patients' safety and comfort."

Writing in the New York Times' "Well" blog this week, physician Lawrence Altman asks: "How is it that a leading medical professor like Dr. Relman… might not have known about the value of modern-day Florence Nightingales?"

Altman spoke with a number of doctors about Relman's inpatient ordeal. Relman's article is a "testimonial to the best emergency medical care and a tremendous will to live," and at the same time "it betrays a surprising lack of awareness of some critical aspects of the medical profession and the nation's fragmented health care system," Altman writes.

'How long have I got left?' A doctor-turned-patient struggles with the question

Relman: A patient's-eye-view of nurses, doctors

Relman was rushed to Massachusetts General Hospital (MGH) in Boston after a fall down the stairs left him with a cracked skull and three broken vertebrae. At the major teaching hospital, students, interns, and residents provided the 90-year-old physician with around-the-clock treatment. Later, he moved to a rehabilitation hospital, where he described the nursing care as "sometimes excellent but often inadequate" and noted that no single physician appeared to be taking charge of his case.

Reflecting on what he learned from his hospitalizations, Relman wrote that physicians "now spend more time with their computers than at the bedside." As a result, "What personal care hospitalized patients now get is mostly from nurses."

He explained, "I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled. This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good."

Altman: Why doctors underappreciate nursing

In Altman's discussions with other physicians, many suggested that the culture of medicine may be responsible for physicians failing to understand the value of nurses, and training is an important component of that care.

For instance, young doctors are trained during rounds in which they follow physicians through the hospital as they teach and impart wisdom that will have a major impact on how doctor trainees practice medicine for years to come. During rounds at MGH, many physicians preferred to remain in the hallway outside the patient's room, relying on test results and vitals to plan further care.

This behavior can appear "impersonal, perceived perhaps as a way of shielding bad information," Atlman notes, adding that instead of going to the bedside, physicians rely on nurses for the "crucial elements in patient care—the physical touch and the personal touch."

Further complicating the matter is the recent surge of medical technology, that has made work "vastly more complicated" for hospital staff, Altman says. "[T]echnology's monitors, images, and devices can deflect [a] doctor's attention," as evidenced by Relman's hospital records, which Relman described as consisting mainly of technical data and little descriptions of his actual progress and mental state.

Chen: Overcoming the gap between doctors and nurses

"In many ways, Dr. Relman's insights reflect changes and generational gaps in training doctors, nurses and other health professionals. Because these disciplines have traditionally been taught in separate silos, they often do not work as tightly as they should," Altman writes. But as efforts to increase care coordination pick up steam, "perhaps the next generation of doctors will no longer be surprised at the importance of nurses and other allied professionals" (Altman, "Well," New York Times, 2/10; Relman, New York Review of Books, 2/6).

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Perfecting the patient care strategic plan

With this infographic from the Nursing Executive Center, learn about the 13 patient care services objectives that hold the greatest promise for advancing strategic priorities and safeguarding hospital margins while elevating care quality.


Experts: Subsidized ACA plans can cost up to 9.5% of one's income

For many middle-income families, the mandate penalty may be less costly

February 12, 2014

For nearly three million U.S. residents with annual incomes three to four times the federal poverty level (FPL), the price of coverage under the Affordable Care Act (ACA) might be unaffordable, experts say.

White House to let consumers switch exchange plans

Under the ACA, U.S. residents purchasing coverage through the health insurance exchanges could be eligible for federal subsidies to offset the cost of coverage. However, those subsidies are tied to the federal poverty level and decrease in value as a person's income increases.

For example, individuals with incomes up to twice the FPL, or about $23,000 for an individual and $39,000 for a family of three, will pay 2% to 6% of their income toward monthly premiums before qualifying for a federal subsidy. Those with incomes of two to three times the FPL will pay up to 8% of the premium cost, while those with incomes three to four times the poverty rate will pay up to 9.5% of their income toward health care premiums before they qualify for subsidies.

By comparison, studies by the Urban Institute show 50% of U.S. residents spent 3.1% or less of their annual incomes on health care before the ACA went into effect, in part because many were covered by employer-sponsored policies, which typically contribute higher amounts to workers' health plans. About 25% of U.S. residents spent at least 8.2% of their incomes on health care, including premiums and out-of-pocket costs.

Observers note that for many middle-income families, paying the penalty for remaining uninsured would be more affordable than purchasing coverage. 

IRS may be unable to enforce the ACA's individual mandate

John McDonough—a Harvard professor who served as an adviser to the Senate Committee on Health, Education, Labor and Pensions during ACA negotiations—said the 9.5% benchmark was included simply as a means to keep costs down and pass the bill. He noted that if Congress does not act to lower that benchmark, coverage "won't be affordable to everyone who needs it" (Appleby, KHN/USA Today, 2/8).


43% of identity thefts are related to health care

Health care organizations experienced 267 breaches in 2013

February 12, 2014

About 43% of all reported identity thefts in the U.S. in 2013 were medical-related, according to a study released last month by the Identity Theft Resource Center (ITRC).

Medical identity theft refers to fraudulently obtaining personal data—such as names, Social Security numbers, or health insurance numbers—to illegally gain access to medical services or devices, insurance reimbursements, or prescription drugs.

According to the report, in 2013:

  • Health care organizations experienced 267 breaches, or 43% of all breaches;
  • Businesses, including retailers, technology companies and others, experienced 210 breaches, or 34% of all breaches; and
  • Financial institutions experienced 23 breaches, or 3.7% of all breaches.

The report found that thieves usually obtain information by:

  • Hacking into computer networks; or
  • Stealing laptops.

Between 27.8 million and 67.7 million individuals' health records have been compromised since HHS began tracking data breaches in 2009.

ITRC legal analyst Sam Imandoust says most identity thieves mine data for insurance records to purchase prescription drugs. Imandoust also noted that one million medical records were reported stolen in 2013 but that the number is most likely much higher because some providers do not report breaches.

Experts: Stolen patient data is most lucrative form of identity theft

He noted that patient records are worth $50 to $500 each (Ollove, USA Today, 2/7; Jayakumar, "Wonkblog," Washington Post, 2/5; Kim, "Marketplace," American Public Media, 2/6).


FDA is doing a lot to stop Rx shortages—but they're more frequent than ever

Agency prevented 154 shortages in 2012, GAO reports

February 12, 2014

Although FDA is getting better at preventing drug shortages, the overall number of shortages increased in 2012, according to a Government Accountability Office (GAO) report released this week.

FDA releases strategic plan to manage, prevent drug shortages

The 2012 FDA Safety and Innovation Act gave FDA greater authority to oversee drug quality and to address any potential drug shortages. Under the legislation, drugmakers are required to notify FDA of any shortages, and the agency is required to maintain databases on the drug shortages and create plans to address them. The act also called for GAO to issue reports on whether FDA has improved its response to drug shortages.

The first such GAO report found that FDA prevented 154 potential shortages in 2012, up from preventing 35 shortages in 2010. However, it also found that the overall number of shortages increased from 154 in 2007 to 456 in 2012.

In total, the agency received 1,132 drug shortage notifications between January 2007 and June 2013. Of those shortages, about 64%, or 722, lasted for less than one year. Fourteen percent lasted longer than two years, and some of the shortages lasted four or more years.

According to the report, the shortages most often affect sterile injectable drugs, primarily because the factories that produce such drugs tend to be older and more prone to problems with quality, which in turn causes delays. However, GAO also found that the larger numbers of shortages were also affecting the heart medicine nitroglycerin and a paralysis drug called cistracurium.

GAO said in the report that 70% of the drug shortages resulted from either drug quality issues and manufacturing delays or shutdowns related to drug quality. Other causes included:

  • Economic factors, such as drugmakers' low profit margins and changes in Medicare's reimbursement rate and in how group purchasing organizations negotiate for drug prices;
  • The limited number of drugmakers, which makes it difficult to mitigate the effect of a shortage when it occurs; and
  • An increased number of drugs produced by generic drugmakers, which puts additional strain on the limited number of producers and factories.

The report commended FDA for the increased number of averted shortages, but it said the agency could take a more proactive stance by creating databases to identify patterns in order to help prevent more shortages.

Douglas Throckmorton, an FDA official who works on drug shortages, said at a congressional hearing on Monday that the agency reduced the number of drug shortages in 2012 for the first time in several years. He added that current data show a similar trend for 2013, arguing that FDA has been able to tackle the problem of drug shortages more aggressively in part because of the agency's increased authority (Tavernise, New York Times, 2/10; Ritger, National Journal, 2/10).


Still struggling with ICD-10? ICD-11 gets a new release date

New codes will be revealed in 2017

February 12, 2014

The World Health Organization (WHO) last week released a fact sheet noting that the final version of ICD-11 will be released in 2017, two years later than scheduled.

Doctors, hospitals continue to work on transition to ICD-10

U.S. health care organizations are working to transition from ICD-9 to ICD-10 code sets to accommodate codes for new diseases and procedures. The switch from ICD-9 to ICD-10 code sets means that health care providers and insurers will have to change out about 14,000 codes for about 69,000 codes.

In August 2012, HHS released a final rule that officially delayed the ICD-10 compliance date from Oct. 1, 2013, to Oct. 1, 2014, partially to look at the incremental changes needed in reforming health care.

Last week: Fewer than 10% of practices are ready for ICD-10

WHO signals later release date for new ICD-11 codes

Development of ICD-11 began in April 2007 and originally was scheduled to be implemented by 2012. The rollout then was delayed until 2015.

The agency had been considering for several months delaying ICD-11 implementation.

Although no official announcement has been made, the WHO fact sheet states that "the 11th revision process is underway and the final ICD-11 will be released in 2017." Meanwhile, a notice posted on WHO's classifications page also notes that ICD's 11th stage is due by 2017.

According to Clinical Innovation & Technology, delaying the IDC-11 rollout "seems appropriate," as several surveys and reports have found that health care providers are lagging behind in their preparations for the transition to ICD-10 codes (Gregg, Becker's Hospital Review, 2/5; Walsh, Clinical Innovation & Technology, 2/4; Bowman, FierceHealthIT, 2/4).


Eye-catching infection forces Bob Costas out of Olympics—for now

Conjunctivitis takes perennial Olympics host off the desk for the first time since 1988

February 12, 2014

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Bob Costas has spent the last couple days battling conjunctivitis on prime-time television, but the infection eventually spread to both eyes and forced him off the prime-time Olympics desk for the first time since 1988.

When Costas began hosting the first events of the Sochi games on Thursday, he had an evident conjunctivitis infection in his left eye, generating much buzz on several social media platform.

Conjunctivitis —better known as pink eye—is the most common infection in the United States and can be caused by bacteria and viruses, or by allergies and chemicals. It causes inflammation in the membranes that cover the white parts of the eye. Describing his condition, Costas said, "You hear it called pinkeye or conjunctivitis, but, as a practical matter, I haven’t had it before. You have swelling and stinging and burning and eventually tearing."

By Sunday, the infection had spread to his right eye. And on Tuesday morning, the perennial Olympics host says both his eyes were swollen and crusted over. A little later that day, he told NBC's Matt Lauer that he would step away from the anchor's desk, "at least [for] tonight." He said, "I was trying to throw a complete game here, but I think we're going to have to go to the bullpen."

Costas' absence from the anchor desk on Tuesday night ended his streak of anchoring 157 straight Olympic prime-time broadcasts for NBC.

Meet the doctors behind Team USA

Costas says the last time he was sidelined by illness was in 1990, when he got food poisoning right before he was supposed to broadcast an AFC championship game.

"I woke up that morning with food poisoning, which is as lousy as you can feel while knowing you're not going to die," he recalls, adding, "They took me to the hospital, and, as I remember, I took my suit thinking they'd stick me with an IV and I'd still go to Mile High Stadium. But then the ceiling started to spin over my head. And I recall a nurse saying to me, with IVs in my arm: 'I know you from television. You look different'" (Boren, Washington Post, 2/11; Sandomir, New York Times, 2/11; Good, "Good Morning America," ABC News, 2/11; Park, "Healthland," TIME, 2/11).


The latest executive transitions

This week's industry transitions

February 12, 2014

Each week, the Daily Briefing highlights executive transitions among the nation's hospitals and health systems. Are you moving to a new institution? Please email transitions@advisory.com to let us know.

New: See our interactive map of 2013-2014 executive transitions. (A list of the most recent transitions follows below.)

CEO Transitions Other Executive Level Transitions
  • Nancy Gaden named CNO at Boston Medical Center (Boston, Mass.)
  • Brad Langdorf named CNO at SouthEast Alaska Regional Health Consortium (Juneau, Alaska)
  • John Countzler named CEO at Muhlenberg Community Hospital (Greenville, Ky.)
  • David Kreye named CEO at University General Hospital (Houston, Texas)
  • Ron Farr named CFO at ProHealth Care (Waukesha, Wis.)
  • Andrew Jahn named CEO at Sonora Regional Medical Center (Sonora, Calif.)
  • David Michael named CMIO at Vidant Health (Greenville, N.C.)
  • Alastair Bell named COO at Boston Medical Center (Boston, Mass.)
  • Tracie Burriss named CFO at Wills Memorial Hospital (Washington, Ga.)
  • Stephen Farber named CFO at Kindred Healthcare (Louisville, Ky.)
  • Jennifer Peters named Chief Operations Counsel at Lifepoint (Brentwood, Tenn.)
  • Tom Zweng named CMO at Novant Health Matthews Medical Center (Matthews, N.C.)
  • Betsy Hunsicker named CEO at West Valley Medical Center (Caldwell, Idaho)
  • Davit Putt named CEO at Grenada Lake Medical Center – Grenada – MS and Holmes County Hospital (Lexington, Miss.)
  • Joe Stampe named President of Meridian Health Affiliated Foundations (Neptune, N.J.)


Daily roundup: Feb. 12, 2014

Bite-sized hospital and health industry news

February 12, 2014

  • Arizona: Banner Health has agreed to acquire Casa Grande Regional Medical Center, which filed for bankruptcy protection earlier this month.  The 187-bed hospital cited Medicaid reimbursement and eligibility cuts as a reason for the bankruptcy. The $87 million deal must be approved by the court (Evans, Modern Healthcare, 2/10 [subscription required]).
  • Illinois: A group of unknown men wrote the message "HI MOM GOD BLESS" on the roof of the parking deck rooftop at Rush University Medical Center in Chicago on Sunday morning. The message could be seen by as many as 80 hospital rooms in the surgical, oncology, and intensive care units. Hospital spokesperson Deb Song said the message inspired patients and staff. "We are trying to find out who put the message up there because it has made so many staff and patients smile," she says (White, CNN, 2/11).
  • Oregon: The state Legislature is considering two bills that would limit access to e-cigarettes for minors. The legislative proposals would make it illegal to sell e-cigarettes and their nicotine-based liquids to any individual under age 18. One of the two bills would also make it illegal to use the devices inside public buildings and workplaces (Garland, AP/Sacramento Bee, 2/10).
  • Oregon: The staff of Oregon State Hospital is pushing the state Legislature to make assaults on hospital employees felonies rather than misdemeanors to make them more of a priority for prosecutors. The issue arose in 2013, when staff at the hospital told legislators that a group of patients was regularly assaulting staff at the hospital without being prosecuted. Lawmakers allocated funds for a part-time district attorney dedicated to prosecuting crimes at the medical center, but staff say that has not resolved the issue (Hoffman, Statesman Journal, 2/11).