The Health Insurance Exchanges of the Affordable Care Act Open Today

The lead up to the government shutdown and today’s opening of the health insurance exchanges have once again brought about a lot of talk about the Affordable Care Act (e.g. Obamacare).  Many Americans are confused about what the Act has brought and what it will bring.

It is a fact that the United States is the only developed country in the world where all citizens do not have health insurance. And, it is clear that some Americans are afraid of the Affordable Care Act in part because of the positions taken by many elected officials.

What people should understand is that several parts of the Affordable Care Act have already gone into effect:

1. The children of workers who have employer sponsored health insurance can now stay on their parent’s plan until age 26. 
2. As of January 1, 2014, insurance companies will no longer be able to deny an individual coverage because of preexisting health conditions. Until now, if you were born with or acquired a disease that would cause you to use your insurance to pay for care, the insurance company could refuse to insure you as an individual. If you were part of an employer sponsored plan or had Medicare or Medicaid, this did not apply to you and you were covered. What many people don’t understand about this part of the Act is, for insurance companies to be able to cover the cost of sick people with preexisting health conditions, there must also be healthy people in the mix. This is called community rating. As a result, the Affordable Care Act requires that everyone have health insurance – either through the government, a private employer or through purchasing individual coverage through the new healthcare exchange. This is called the individual mandate. 

Which brings us to today, October 1, the date the health care exchanges open for everyone who does not have health insurance to purchase individual coverage that will take effect on January 1, 2014. 

Mitt Romney created the idea of these healthcare exchanges when he was Governor of Massachusetts. Governor Romney thought that it was wrong that so many working people did not have health insurance and he also knew that Massachusetts hospitals had huge amounts of bad debt from individuals who got sick and couldn't pay their bills. The State of Massachusetts wound up covering this debt. Governor Romney was also concerned with the cost of health insurance for business owners who were already covering their employees and he wanted to create a true market where insurers would compete for customers and drive costs down. He also recognized that once you start requiring individuals or small employers to buy insurance, you must help them by creating a true market. President Obama’s people later recognized that the notion of health insurance exchanges was a good idea, which is why it is part of the Affordable Care Act. And again, individuals with preexisting conditions will not be excluded (which is great).

One of the big misconceptions of this law is that it contains “government run” healthcare. There is NO provision in the law for the government to provide care. 

Our government already purchases care for everyone over age 65, which is called Medicare. It purchases healthcare for many of the poor and disabled along with the States through Medicaid. Our government purchases care for federal employees. It is true that our federal government already provides care directly to our veterans through the Veteran’s Administration (VA). In fact, the VA, the military medical systems, and the National Institutes of Health are the only organizations where government employees provide care. There is NO new government run healthcare within the Affordable Care Act.

Additionally, one of the major portions of this act that has already taken effect is the Medicare Shared Savings Program. The GBMC Healthcare System is participating in this program through the Greater Baltimore Health Alliance (GBHA) which we created in 2011. The Board of GBHA is over 75% physicians with Dr. Anthony Riley, head of geriatric medicine at GBMC, as the Chairman of this board.

The incentive here is for doctors to work towards the triple aim for those with Medicare:

1. Better health and health outcomes for the Medicare beneficiaries
2. A better care experience for Medicare beneficiaries
3. Lower costs for beneficiaries and the Federal government

Early first year results for GBHA’s participation in the Medicare Shared Savings Program shows that we have saved about 7% per beneficiary. If we improve our quality parameters and save money, some of the savings are then shared back with the doctors participating in GBHA and GBMC.

This is another part of the law that I think is good for Americans. It’s driving value in healthcare. Notice that there is no money given back to the providers unless the quality and patient satisfaction goals are achieved and money is saved. Most people believe this is good because if we don’t drive Medicare costs down, we could bankrupt the country.

Every American has the right to dissent – it’s one of the wonderful things about our country. But every American also has the duty to review the facts before they make up their minds.

So, regardless of what happens (although it does not appear there will be changes to the Affordable Care Act) GBMC will not deviate from its vision – to treat every patient, every time the way we would want our own loved ones to be treated. And we will continue to measure our progress towards our four (or quadruple) aims: better health, better care, with the least waste, and the most joy for those providing the care.

****

Babies small and grown who were born at GBMC and parents of GBMC babies 

Finally, this past Saturday, GBMC’s Foundation held its 13th annual Legacy Chase at Shawan Downs. It was a fine fall day in the sun celebrating our vision and commitment to families and the community. Through the 2013 Legacy Chase event we have raised more than $1 million in commitments toward the Endowed Chair in Pediatrics. Close to 8,000 people came out to support this great event which also included several special reunions. This year marked the second year of our annual NICU reunion to celebrate the milestones of our smallest patients and GBMC’s volunteer auxiliary also celebrated its 50th anniversary! And, we had a wonderful group photo taken of babies born at GBMC (above) where several generations made this reunion truly special.

I thank all those who attended and all those who donated time or treasure. Kudos to the GBMC Foundation for another successful, fun-filled event. There’s still time to support the cause by visiting http://foundationevents.gbmc.org/.

Perfecting the Hand-Off – to Better Coordinate Care

Our vision is to treat everyone as we want our own loved ones treated. Most of us have had loved ones with some chronic disease where our loved one was caught between providers of care and we had to try to bridge the gap. I often get calls from family members asking me to help resolve differences of opinion between providers. I have told the story of a woman who was admitted to the medical intensive care unit at GBMC with diabetic ketoacidosis because her insulin plan was wrong. Our physicians and nurses got her back on her feet and discharged her to the care of her doctor. Unfortunately, her doctor put her back on her previous plan and she ended up back in the Emergency Department. It seems that her doctor did not get the message about her new plan at the time of her discharge. A clear lack of coordination.

How do we fix this? 

Well, the improvement has to start with someone being willing to coordinate the care. This is why the GBMC HealthCare system has embraced the concept of the patient-centered medical home (PCMH) because the physician-led team knows that it is accountable to provide the coordination 24 hours a day, 365 days of the year, and actually has the capability to do that! Also, the other members of the healthcare system must work with the primary care teams at the time of handoff, like when a hospitalist is discharging a patient from GBMC back to the primary care physician.

The Head of the GBMC hospitalist group, Rekha Motagi, MD, and her team have been working tirelessly to improve the handoff back to the primary care doctor. You can imagine that communicating to literally hundreds of different doctors and offices can be quite a challenge. Rekha and her colleagues have been redesigning their communication process and measuring its performance as a measure on their Lean Daily Management board. Every day on our management rounds, Rekha or one of her hospitalist colleagues and members of our two internal medicine resident teams, report on the percentage of the previous day’s discharges where they have had a high quality communication with the primary care physician or his or her office staff. As a result of their work, they rarely miss a handoff with a GBMA PCMH practice and we are seeing improvement with our non-GBMA practice colleagues as well.

I’ve asked Dr. Motagi to explain the obstacles that have been identified and the improvements that have been made in the transition of care since the team started testing changes:

Rekha Motagi, MD

Dr. Motagi explains: 

The hospitalist group has always made it a priority to communicate with a patient's primary care physician to provide verbal hand-off when patients are discharged from the hospital. This is a very important aspect of the transition of care. Reviewing a patient’s hospital course, medication changes, test results and pending tests during this hand-off is also an important patient safety measure.

Previously, we were not sure how consistently this hand-off communication was occurring in our large group and the reasons we were not always successful. But since we started the lean daily management process, where one of our metrics is for each physician to note if they have been able to reach the PCP for discharge hand-off, we have identified several areas for improvement.  

About 90% of the time, our doctors have made an attempt to reach the patient’s PCP; but we've only connected with them from 50-70% of the time due to various reasons including:

• Offices were closed or the front office did not want to interrupt the PCP. In these instances, we left a message but were not sure if the PCP received it (This becomes much more challenging on weekends/holidays.)
• We have been put on hold for 10 minutes or more; in many instances, our doctors have had to hang up because they needed to respond to other calls
• The PCP was on vacation, so there was no way to ensure they received the message
• There is no attempt made to call when there is no PCP or if the patient is going to be transferred to a facility and no provider in the facility has been identified

Since we started Lean Daily Management, the physicians relations office (Mary Ely, Ann Veltre and Bonnie Longerbeam) has been working to reach out to several physician groups to obtain their feedback on the best ways to accomplish a successful transition of care. What we've found is that there are some PCPs who are very involved in their patient's hospital stay. Some are interested in receiving the call from the hospitalist, but only call back if they have questions. From this outreach, we've been able to make improvements and design a more effective system for coordinating the transition of care, including:

• Obtaining back-office telephone numbers for PCPs (and in some cases cell phone numbers) which provides us with faster access to some of the PCPs
• Updating incorrect physician office numbers in our database 
• Identifying physician offices that have care co-coordinators (RNs) who will take the patient’s information, relay it to the PCP and contact patients to arrange follow-up

We are now working with all primary care providers to further standardize this process. Our group is also committed to making sure the written communication (discharge summary) is completed within 48 hours of a patient being discharged. Currently, we are over 95% compliant with this effort and we are working to get this rate to 100% so that the information is there for the PCP to use in follow-up.

***

I want to thank Dr. Motagi, our hospitalists, our internal medicine residents, the physician relations group and our PCPs for their commitment to creating a more reliable system for patient hand off. Continuous improvement requires a focus on who it is that we are serving, system design, measurement, teamwork, and empowerment. Lean daily management appears to be helping us speed up the implementation of all of the above!

Honoring, Remembering One of GBMC’s Founders, Mrs. Jeanne H. Baetjer

Last week, GBMC lost an inspiring and visionary leader. Mrs. Jeanne H. Baetjer, one of GBMC’s founders, passed away at the age of 91 years. What a legacy she left behind. Mrs. Baetjer was a true leader in every sense of the word. Her strong sense of community was quite evident in her life’s work, which included her vision for the development of a community hospital in Towson.

In 1958, while serving as President of the Hospital of the Women of Maryland, of Baltimore City, Mrs. Baetjer and other community leaders saw the need for a hospital in this area and set out to work on making this vision a reality. This was no small feat as the creation of GBMC entailed combining The Hospital for the Women of Maryland, of Baltimore City (Women’s Hospital) with the Presbyterian Eye, Ear, and Throat Charity Hospital. But, her tenacity and dedication to filling a greater community need paved the way for the establishment of our hospital, and from 1962 to 1965, while building was underway, Mrs. Baetjer oversaw the massive project. Her commitment to GBMC spanned five decades and she served in various roles in our history including the very first President of the Board of Trustees.

Since GBMC first opened its doors to the community in 1965, we have cared for countless individuals and we are forever grateful for Mrs. Baetjer’s vision and dedication. Her impact on GBMC and the community is immeasurable and far reaching. To this day, GBMC embraces her guiding principle that the patient always comes first– through our current Vision of “to every patient, every time, we will provide the care that we would want for our own loved ones.”

Please join me in honoring her life and legacy by sharing your memories and thoughts about Mrs. Baetjer with our blog community.

What can we do to make GBMC safer for our people?

Our fourth or “quadruple” aim is more joy for those providing the care. All of us in our healthcare system should derive joy from serving those in need. But how can work be joyful if it is not safe? Safety on the job is surely relative. There are many jobs that have higher risk of injury than working in healthcare. Nonetheless, it is unethical to not be working toward zero injuries among our people.

The run chart below shows the monthly number of injuries reported to employee health. 

In fiscal year 2013, which ended on June 30th, we had 327 injuries. That number is an improvement of 12% from fiscal 2012’s 370 injuries. We have set a goal of no more than 294 injuries in fiscal 14, a further 10% reduction. Our Senior Executive Team receives a daily report of the number of employee injuries in the preceding 24 hours and measures this on our Lean Daily Management board. We are driving toward a goal of zero injuries.

The injuries can be grouped into a number of large categories. The most dangerous of the injury groups is the needle stick/body fluid splash category. Being injected with hepatitis C or HIV contaminated blood can lead to a lifetime of therapy and/or long term morbidity. These injuries can be prevented by using the appropriate safety devices like needle-less systems, needles with protective sheaths and protective eyewear. A respiratory therapist was recently exposed when the therapist did not use protective eyewear when inducing cough in a patient.

System design is also important. Standard work in the passing of sharps in the operating room is critical to reducing needle stick injuries. Recently, a resident physician stuck himself with a contaminated needle because he used his fingers rather than pickups to reposition a needle on a needle driver.

Another category of injury among workers at GBMC is sprains and strains, usually from lifting. With the national epidemic of obesity, it is very important that we use the appropriate lifting devices to avoid musculoskeletal injuries. Slips and falls is a category of injury that usually occurs from spills that go unnoticed or from workplace clutter. An employee recently fell after tripping on an exposed electrical wire. Our IT Team has recently been doing environmental rounds to make sure that computer and printer electrical cords are not creating tripping hazards on our units.

Our last major category of injuries is those due to workplace violence. We have made some progress in this area by implementing training for employees in high risk areas like the Emergency Department and also by stationing a security guard on Unit 36. There are other injuries that don’t fit into common categories like the employee who was recently harmed when a swinging door came off its hinge.

So what can we do to drive towards zero workplace injuries? First, we can make sure that we are following safe practices and using protective devices when appropriate. Secondly, we can report all injuries and participate in the learning from injuries to make our systems even safer. Thanks very much for sharing your ideas on how we can reduce employee injuries in the GBMC HealthCare system.

A Day of Remembrance

Finally, tomorrow is a somber day for our nation as we remember those we lost on September 11, 2001. It’s hard to believe it has been 12 years since that tragic day in our country’s history. We should all take some time out of our daily lives to reflect on the sacrifices made by our first responders and every day citizens. Instead of focusing on the inhumanity and the horror of the day, let us focus on the many stories of hope and humanity that we witnessed as people came together to help others in any way possible. It’s the examples of humanity that keep us strong and we hope that by remembering incidences of the past, we can grow and change to create a better future. My thoughts are with everyone touched by this tragedy as we remember and hope for a more peaceful tomorrow.

A Reflection on the Meaning of Labor Day

As our country celebrated the hard work of the American people during the Labor Day holiday on Monday, many of us enjoyed the three-day weekend which has also come to symbolize the unofficial end of summer. But, Labor Day is also an opportunity for us to reflect on what we have accomplished and will continue to achieve, and to thank the people that make our health system and our country strong because they go to work every day and put their best efforts toward serving a need. At GBMC, we are fortunate to be able to meet the important need of helping others by delivering to everyone the care that we want for our own loved ones.

And as I reflected on the true meaning of the Labor Day holiday, I realized how thankful I was for the efforts of the entire GBMC staff - from the doctors, nurses, and technicians to our food services workers, environmental service staff and parking attendants.  Every individual at GBMC is an important part of the collective team and I see the great efforts our team puts forth to provide the very best care to patients every day.

I also reflected on what it means to have a job, especially with the way our economy has been over the past six years or so. Now that I have four children who have graduated from college, I see how hard it is to find a good job that you love. I am grateful for my job, which I competed for and was delighted to get. GBMC is a great organization with a great vision and a great future. I know what it means to love what you do and I am honored to work with such dedicated individuals.

I have been talking a lot about standard work, processes and systems, but as we celebrate Labor Day and look ahead I need to remind myself that what makes a healthcare system truly outstanding is not the technology or the facilities, but the people.

“I Think They Forgot to Reset the Bed Alarm.”

Recently, a man and his daughter came to see me in my office. They were upset because their wife and mother had fallen and broken her hip while an inpatient at GBMC. She had come in for an elective surgical procedure and was a bit disoriented post-operatively. A unit staff member had helped the patient out of bed in the middle of the night and had then assisted her back into the bed. Sometime later, the patient tried to get out of bed again to visit the bathroom and fell, fracturing her hip. It seems that the staff member who helped the patient out of bed had forgotten to reset the bed alarm so that when the patient got up on her own, the alarm did not sound and the staff was not alerted to the impending danger. The staff had correctly identified this patient as high risk for falls and had the appropriate equipment for fall prevention in the room.

Reliability means what should happen, happens, and what should not happen, doesn't. In this case, a woman under our care fell and sustained a serious injury. This should not happen. But why did it happen and what should we do to make sure it doesn't happen again?

Our Falls Team has dramatically reduced the number of falls at GBMC. Preventing falls in the hospital, especially among the physically compromised, is very difficult. It requires vigilance among the staff, and standard work using evidence-based care to do this. One miss, as in this case, can cause serious injury. Until a few months ago, we had high defect rates in the use of all of the important safety devices (alarms, socks, wrist bands, and signage) on some days on some floors. Now, it is very unlikely that a high fall risk patient doesn't have all of the equipment in place. But even with the equipment in the room, most of our beds have alarms with a design flaw: to take a patient out of bed safely you first shut off the alarm, and when you put the patient back in the bed you have to remember to turn the alarm back on.

These bed alarms are examples of active safety devices. The problem with such devices is that they require an action on the part of a human to operate correctly. But humans are not perfect and they sometimes forget, especially when busy caring for many patients at once. If our nurses care for 80 patients a day with bed alarms, and the patient gets out of bed five or six times a day, that’s almost 500 times a day the staff must remember to reset a bed alarm. Our nurses and technicians work so hard it is easy to see how one of them could get distracted and forget to reset the alarm. But if we get it right 499 times out of 500, and the one time we miss results in a patient injury, we still have to find a way to get to perfection.

In the old days, our reaction here would have probably been to reeducate the staff on the importance of resetting the alarm. This action is silly at best. When our staff gets something right 99% or more of the time, is it that they don’t know that they should reset the alarm? Of course not, it’s that they forgot, so education is not likely to fix the problem.

High reliability organizations search for passive safety devices – ones that don’t require human action and therefore are much less likely to fail. As a pediatrician who has treated a number of drowning victims, I recall when gates in fences around pools used to require an adult to remember to pull the gate shut to keep young children from wandering into the pool area unattended. Now, most pool gates have a spring that pulls the gate back into the closed position and a self-catching lock…the gate shuts itself after someone enters. Our falls team recognized that even the smartest, hardest-working staff member will eventually forget to reset the bed alarm. GBMC is now beginning the replacement of our beds and purchasing new beds that have alarms that reset automatically. We now have a number of these beds already in place. In the interim, the Falls Team continues to test ways to “catch” that someone has forgotten to reset the alarm.

To err is certainly human; but as humans and as healthcare leaders, we have the ability to redesign our systems so that common human errors are blocked or mitigated before they cause harm. We must study every event and find new ways to make our GBMC HealthCare system safer every day.

Let me thank everyone in the GBMC family for helping us get to higher reliability and closer to our vision.

GBMC’s Annual Goals – How We Know If We are Getting Closer to Our Vision

The GBMC HealthCare System has a vision of perfection. Our vision is to deliver the care that we want for our own loved ones to everyone, every time. Since we are human and our designs are created by humans, we know that we will never truly get to perfection, but we accept that we must keep getting better. So, how do we know if we are getting better? We see where we are at the end of every fiscal year, we set goals for ourselves, and we then measure our performance on a regular basis (at least monthly) - and we keep score!

At GBMC, we work throughout the year to improve in our four Aims (the areas that best describe the care that we want):
1. Best health outcomes
2. Best satisfaction
3. Least waste
4. Most joy for those providing the care

As we begin this new fiscal year this summer, it’s a good time to look back over the last couple of years to see how far we have come. I am happy to report that year over year, GBMC has seen improvement in most of our aims, but not for every measure, and we still have a lot of work to do:

GBMC annual goals-  Click image to enlarge

Under the Aim of “Best Health Outcomes,” we saw significant improvement in the number of “good catches” and reported events that allow us to ensure patient safety and implement important safety measures. We also reduced total incidents of harm from 190 incidents in FY’ 12 to 96 in FY’ 13, and our plan is to decrease the number of incidents even further in FY’ 14. Again, this reduction is due in large part to the safety processes and redesigned systems put in place by our team members.

If you look at the aim of “Most Joy,” we are focusing efforts not only on reducing employee injuries but also improving our employee and physician satisfaction. We know that when our employees and physicians are satisfied and happy with their work and work environment, our patients truly benefit. We’re still waiting for FY’13 actual scores, but I’m confident that we will meet our goals in this area.

Meeting our annual goals, and in some cases exceeding them, is a result of the hard work and dedication of our staff as well as new processes and redesigned systems that have enabled us to work more efficiently and effectively for our patients. The results show that new initiatives and redesigned systems help us ensure better health outcomes, while improving patient satisfaction, reducing waste throughout the system, and increasing the joy our staff experience delivering the high level of care.

I thank all GBMC employees for doing their part to help ensure we keep moving toward our vision, and ask that everyone continue to work toward even better results in FY’14.

Finally, I’d like to welcome to the GBMC team, Tanya Townsend, who recently joined us as Vice President and Chief Information Officer. She comes to us from Wisconsin where she was the Chief Information Officer at the Eastern Wisconsin Division of the Hospital Sisters Health System in Green Bay. Tanya’s background as a leader in healthcare IT and her experience with standardizing systems will surely benefit our organization. Please join me in welcoming Tanya to the GBMC family.