The Daily Briefing

News for Health Care Executives

HealthGrades names 'Top 50 Cities for Hospital Care'

Baltimore, Phoenix, and Cedar Rapids top the 2012 list

January 24, 2012

HealthGrades on Tuesday released its list of "America's Top 50 Cities for Hospital Care" based on an analysis of risk-adjusted patient mortality and complication rates at almost 5,000 hospitals nationwide.

As part of its 10th annual HealthGrades Hospital Quality and Clinical Excellence study, HealthGrades identified "Distinguished Hospitals for Clinical Excellence"—hospitals performing in the top 5% nationwide for 26 medical procedures and diagnoses—then ranked cities by highest percentage of Distinguished Hospitals.

According to the analysis, the top 10 U.S. cities for hospital care are:

    1. Baltimore;
    2. Phoenix-Prescott, Ariz.;
    3. Cedar Rapids, Iowa;
    4. Richmond, Va.;
    5. Cincinnati;
    6. West Palm Beach, Fla.;
    7. Chattanooga, Tenn.;
    8. St. Louis, Mo.;
    9. Hartford-New Haven, Conn.; and
    10. Grand Rapids-Kalamazoo, Mich.

In top-ranked Baltimore, 47% of hospitals were deemed Distinguished Hospitals, including Good Samaritan Hospital, Greater Baltimore Medical Center, and Saint Joseph Medical Center.

Based on the data, researchers found that Distinguished Hospitals reported 30% lower risk-adjusted mortality rates and nearly 2% lower risk-adjusted in-hospital complication rates than other hospitals.

Overall, they estimated that if all hospitals performed at the level of Distinguished Hospitals, 165,704 Medicare beneficiaries' lives could have been saved and 6,800 Medicare in-hospital complications could have been avoided across the study period (HealthGrades release, 1/24; HealthGrades study, 1/24; HealthGrades methodology, 1/24).

Five things to watch in the State of the Union

How health care will, and won't, be a factor tonight

January 24, 2012

Dan DiamondDan Diamond , Managing Editor

And the state of our health reform is…

Good? Strong? Awaiting Supreme Court review?

Don't expect President Obama to render a verdict tonight.

With the president slated to deliver his fourth—and possibly final—State of the Union at 9 p.m. ET, all signs point to a speech that skimps on health care and focuses on the broader economy.

Even if Obama barely celebrates his Affordable Care Act, health reform will have a place in tonight's remarks. But you may need to look harder to find it than in years past.

Here's what to watch.

1. How many words go toward health care 
Obama has seemed leery of saying five things about health care—let alone five words about his ACA—in recent months.

But no president since Ronald Reagan has completely ignored health reform in a State of the Union address. (President George H.W. Bush came closest; his plan warranted just 47 curt words amid a Gulf War-focused 1991 address.)

And health reform had been a major theme in Obama's first two addresses. The president spent more than 1,000 words to first outline his vision (2009) and then pled with Congress to keep the ACA alive (2010).

But the law's persistent unpopularity forced a retreat last year, setting up this striking contrast:

  • Obama used only 224 words—about 3% of his speech—to tersely tout his own signature policy achievement.
  • Rep. Paul Ryan devoted more than 12% of the Republican rebuttal to condemn the ACA and promise a GOP-led repeal effort.

Expect a reprise tonight. Obama's failed attempts to win over the ACA's critics have reportedly left the president frustrated and his advisors convinced he has little to gain by revisiting the issue; facing re-election, he's likely to move quickly to less sensitive topics.

2. Which path Obama chooses: Defense, offense, or diplomacy
However he deals with health reform, The Hill notes that Obama will choose from three potential frameworks.

  • Defend his health care law: This would speak to the president's core supporters, some of whom are frustrated that Obama hasn't kept trumpeting his most transformative reform.
  • Criticize Republicans' Medicare privatization plans: This is House Democrats' preferred approach, and a potentially popular strategy ahead of November's elections. But The Hill reports that the tactic may leave Democrats exposed to similar criticism, given the party's own proposals to trim health spending.
  • Reiterate his willingness to make changes: This would be Obama's latest effort to cast himself as a bipartisan leader; the president last year said he was "eager" to improve the ACA and the Washington Post credits his follow-through in striking down the law's controversial 1099 provision.

After years of trying to seek consensus, pre-speech rumblings suggest that Obama's latest State of the Union will be more aggressive and combative than in years past.

3. Why Obama thinks the ACA has been a success
Obama's recent campaign appearances reveal several new talking points about health reform, which will likely come up in his speech.

The president has stressed how 2.5 million young Americans have gained health coverage through the ACA, thanks to provisions that allow adult children to stay on their parent's plan. He's further celebrated the law's discounts for seniors' prescription drugs and protections for patients with pre-existing conditions.

Obama also has been testing a new slogan: Change is.

"Change is the health care reform that we passed after a century of trying," Obama told supporters in Washington, D.C., this month. "Millions of Americans who can no longer be denied or dropped by their insurance companies when they need it most…That's what change is."

Those lines may play better at a private campaign event than in front of a divided Congress. We may find out tonight.

4. Where the jobs are (or aren't)
When it comes to job creation, no sector is healthier than health care. The industry has produced 800,000-plus jobs since Obama took office. In contrast, the rest of the economy has lost more than 2.4 million.

But while the president is expected to focus on his employment strategy, don't expect a spotlight on the booming health care market.

Pointing up the industry would leave Obama in a tricky position. While the president's chief argument to pass the ACA during a recession was its job-creating potential, he'll want to avoid suggestions that the law merely boosted health care organizations at the expense of other employers.

Still, keep your ears perked for how Obama discusses economic plans like "insourcing"—his idea to bring jobs back to the United States—and the need for American innovation. Both have implications for health care, though in very different ways.

First, growing the health care industry does track with keeping jobs home. Actual health care delivery is essentially local; as former White House economist Jared Bernstein recently told me, you can outsource a manufacturing job to China but can't outsource a nurse. Second, the nation's health IT sector continues to grow, and lawmakers in both parties often invoke necessary initiatives like electronic health records; Obama has touted at least one firm—GalaxE Solutions—in speeches this month.

5. When Obama addresses his rivals—if he does so at all
Presidents don't often cede the stage at the State of the Union, but it's not unprecedented.

Bill Clinton's 1996 address featured several references to Bob Dole—then the Senate Majority Leader and Clinton's Republican opponent later that year.

More common was George W. Bush's approach in 2004: No mention of his rivals and a speech that focused on sweeping, presidential goals while future Democratic nominees John Kerry and John Edwards attacked each other on the primary trail.

Obama has mostly stayed above the current fray in the Republican field. But there's actually an opening for the president to obliquely zing his top challengers.

The White House has delighted in reminding Republican voters that Obama's health reforms were expressly modeled on Mitt Romney's own overhaul in Massachusetts—a sore subject for the Romney campaign.

And despite GOP presidential candidate Newt Gingrich's attacks on the insurance mandate in "ObamaCare" and "RomneyCare," reports continue to surface that Gingrich used to support the provision too. (The two prominent Republicans have company; the conservative Heritage Foundation also backed the mandate.)

But it's about as likely that Obama will explicitly mention Romney or Gingrich as he'll make a joke—like one journalist suggested—that the health reform law is actually "NewtObamaRomneyHeritageCare."

Although that would be something to watch.

For live analysis of the State of the Union tonight, follow Dan on Twitter at

Will ACOs work? Experts—including Berwick—weigh in

Former CMS chief joins two health experts to debate future of ACOs

January 24, 2012

In a Wall Street Journal special health care discussion, former CMS Administrator Don Berwick explained why he thinks the ACO model will succeed where earlier managed care models failed.

For the ACO discussion, Berwick debated the care model with Tom Scully, a former Federation of American Hospitals CEO who led CMS from 2001 to 2004, and Jeff Goldsmith, president of Health Futures Inc.

According to Berwick, HMOs over the years have introduced innovative concepts like clinical teams, care coordination, nurse practitioners, and electronic health records. However, the "mutant forms of managed care" that emerged in the 1970s focused on cost savings without improving care, giving HMOs a bad name, he says.

Today, Berwick notes that "[m]anaged care is on better behavior." Ultimately, he says, the current ACO model "will work because it is set up to reward the right combination of goals for our time: transparency, coordination, consumer power, and intolerance of waste."

Although Scully supports the ACO concept, he points out that the incentives for ACO participants remain "very small." He estimates that the start-up cost of a real ACO is $30 million in a mid-size market, making it difficult for some physicians to take the reins. Instead, he suggests that ACOs "are driving more power to hospitals—not to doctors," even though they aim "to organize doctors to focus more on patients and keep the patients out of hospitals."

Meanwhile, based on previous pilot programs, including the Physicians' Group Practice demonstration, Goldsmith argues that it remains unclear "who the winners are in the ACO." In response, Berwick notes that ACOs are not "a reprise of the Physicians' Group Practice demonstration" (Wilde Mathews, Journal, 1/23).

The suite life: Hospitals ramp up pursuit of affluent patients

Organizations dip toe in marble baths

January 24, 2012

Hospitals continue to add amenities like butlers and marble bathrooms to attract wealthy self-pay patients, but the New York Times notes the strategy is growing more difficult: there's more international competition and greater national scrutiny on hospitals' charitable missions.

Well-off patients who pay out of pocket—and can potentially develop philanthropic relationships with an organization—are especially valuable to hospitals, given ongoing cuts to federal reimbursement and other margin pressures. And luxury suites are necessary to lure the wealthiest patients, design strategists tell the Times, given international hospitals' efforts to woo medical tourists through "glittering" wards and other attractions.

As a result, more urban hospitals are offering "amenities units" with all the perks—and a substantial price tag. A stay at New York-Presbyterian/Weill Cornell's refurbished rooms can cost U.S. patients $1,000 to $1,500 in daily out-of-pocket fees, in addition to whatever base rate insurers pay to the hospital; foreign patients pay $4,500 per day.

Some organizations are targeting a slightly less wealthy group of patients, too. New York City's Beth Israel Medical Center in 2008 added a deluxe ward that is "more Radisson than Ritz"—with a lobby covered in green carpet, as opposed to the proverbial red—and charges $450 per night for a patient stay.

According to Helen Cohen, a specialist in health facilities at the international architectural firm HOK, pursuing the strategy offers demonstrated value; such patients are "the best kind of patient to have," given the trickle-down effect, she told the Times. The 19-bed luxury unit at Mount Sinai Medical Center adds $3.5 million per year, according the center's hospitality director, although Mount Sinai's president stressed that the unit's revenue is a "rounding error" compared to the organization's overall budget.

However, hospital leaders can face a challenging situation when the luxury suites receive attention in the media or draw other scrutiny, according the Times. For example, many urban hospitals have been lobbying Congress against funding cuts by pointing up their roles as not-for-profit teaching institutions that serve low-income individuals (Bernstein, Times, 1/21).

Study IDs factors influencing nurse retention across three generations

Older nurses consider more factors than younger counterparts

January 24, 2012

Nurses from different generations consider varying factors when deciding whether to stay in their job, although they all are influenced by "a strong attachment to healing," a recent study found.

For the study—which was published in the Journal of Advanced Nursing (JAN)—Australian researchers surveyed 900 nurses from seven private hospitals, dividing participants into three groups based on age. Nurses between ages 44 and 46 were deemed Baby Boomers, those between 29 and 43 were considered Generation X, and RNs under 29 were called Generation Y.

According to the findings, six independent variables influenced nurses' intentions to keep working: work-family conflict, on-the-job autonomy, commitment to healing, the importance of working to the individual, supervisor-subordinate relationship, and interpersonal relationships with coworkers. The nurses were not influenced by flexible working arrangements, the study found.

The results showed that older nurses tended to be influenced by a larger number of factors than younger staff. For example, five independent variables were identified in the Baby Boomer group, while two independent variables were identified in the Generation X group. Commitment to healing was the only independent variable identified across all three age groups.

"We believe that the secret to improving hospital nurse retention rates is to build on this commitment to the nursing profession and to tackle the specific variables identified by our study for the three generations of nurses," the authors write.

The authors say the findings could provide insight for developed countries that currently are suffering a nursing shortage. According to the American Nurses Association, only 80% of educated and licensed nurses in the U.S. are working as RNs (Shacklock et al., JAN, January 2012; JAN release, 1/12; The Press Association/NursingTimes, 1/18).

PCORI releases draft research agenda highlighting five priority areas

Group seeking comments from stakeholders

January 24, 2012

The Patient-Centered Outcomes Research Institute (PCORI)—a group of experts created under the federal health reform law to compare the effectiveness of medical procedures—on Monday released a draft research agenda for public comment.

The 22-page draft research agenda highlights five priority areas of comparative effectiveness study. They include:

  • Assessing prevention, diagnosis, and treatment options;
  • Improving health care systems;
  • Communicating research;
  • Addressing treatment disparities for various socioeconomic groups; and
  • Advancing patient-centered and methodological research.

PCORI Board Chair Eugene Washington said, "We want to hear from patients, caregivers, providers and the wider health care community on whether our draft priorities and initial research agenda capture the broad areas where more evidence-based information is needed to make better decisions."

The health reform law allocated $500 million over five years for comparative effectiveness research. The provision has been controversial because some stakeholders said such research could limit physicians' ability to order costly care that might be effective for one person but not necessarily for others (Pecquet, "Healthwatch," The Hill, 1/23; McKinney, Modern Healthcare, 1/23 [subscription required]; Reichard, CQ HealthBeat, 1/23 [subscription required]).


Stewart presses Sebelius on health law provision in 'Daily Show' interview

HHS secretary defends decision on essential benefits

January 24, 2012

In an interview on "The Daily Show with Jon Stewart" on Monday, HHS Secretary Kathleen Sebelius discussed a recent proposal to allow states to determine the "essential benefits" required of plans in the state insurance exchanges under the federal health reform law.

Stewart asked Sebelius why states should be trusted to determine benefits, when many currently lack strong insurance regulations. She said provisions in the overhaul will act as a check on insurers, such as the medical-loss ratio requirement, under which health insurers must spend 80% to 85% of their premium dollars on direct medical costs.

Stewart pressed Sebelius on whether HHS would grant states waivers from those requirements. Sebelius said, "By and large, we have said no" to such requests. The department has agreed to modify the threshold in a handful of states but has rejected most (Baker, "Healthwatch," The Hill, 1/23).

Mobility for Healthcare: The choices and challenges

January 24, 2012

Join The Advisory Board Company’s mobility expert Kenneth Kleinberg for a special webconference hosted by HIMSS. More.


Daily roundup: Jan. 24, 2012

Bite-sized hospital and health industry news

January 24, 2012

  • California: The Veterans Affairs hospital in Fresno has introduced live music to its waiting room, a move that physicians say has improved the patient experience and reduced stress, especially for patients with post-traumatic stress disorder or traumatic brain injury. After noticing patients' positive responses, the hospital now brings in a classical guitar player in addition to its original harp player (Marcum, Los Angeles Times, 1/16).
  • Michigan: Public Citizen's Health Research Group in a letter to Michigan officials recently questioned whether the state has disciplined about 220 physicians cited by their hospitals for bad performance or misconduct. According to the group, Michigan is one of 13 states that has not reported actions against physicians to the National Practitioner Data Bank. Under federal law, hospitals are required to report physicians to the data bank if their privileges are revoked for behavioral reasons (Anstett, Detroit Free Press, 1/18).
  • Minnesota and North Dakota: Sanford Health last week signed a definitive agreement to acquire Bagley-based Clearwater Health Services. Pending final board approval, the 20-hospital system, which already had a management contract with Clearwater, will integrate Clearwater into its system on Feb. 1. Under the deal, Sanford will purchase Clearwater assets and lease Clearwater properties (Robeznieks, Modern Healthcare, 1/17 [subscription required]).
  • Virginia: Duke LifePoint Healthcare last week announced a $20 million investment in Twin County Regional Hospital over the next 10 years, bringing the system one step closer to majority ownership of Twin County Regional Healthcare. Duke LifePoint in October announced plans to take an 80% stake in the system. The transaction will allow Twin County Regional Healthcare's to pay off its debt and create a charitable foundation for new community programs and services (Silva, Nashville Business Journal, 1/20).

Most uninsured residents live in states that lag on ACA implementation

Three out of four uninsured U.S. residents live in states that have not made significant progress in establishing health insurance exchanges under the federal health reform law, according to an analysis by the Associated Press and coverage estimates from the Urban Institute.

According to the analysis:

  • 13 states and the District of Columbia have set up an insurance exchange;
  • 17 states have made significant progress on setting up an exchange; 
  • 16 states have made unclear progress; and
  • 4 states—Arkansas, Florida, Louisiana, and New Hampshire—have made no significant progress.

Uninsured residents of the 20 states that have made little or no progress make up 42% of the nation's total uninsured population, or 21 million of 50 million total, according to Urban Institute estimates (Alonso-Zaldivar, AP/Yahoo News, 1/22; AP/San Francisco Chronicle, 1/22).