(This article was provided by Kaiser Health News.)
Eyeing fast-growing urban and suburban markets where demand for health care services is outstripping supply, some health care systems are opening tiny, full-service hospitals with comprehensive emergency services but often fewer than a dozen inpatient beds.
These “microhospitals” provide residents quicker access to emergency care, and they may also offer outpatient surgery, primary care and other services. They are generally affiliated with larger health care systems, which can use the smaller facility to expand in an area without incurring the cost of a full-scale hospital. So far, they are being developed primarily in a few states — Texas, Colorado, Nevada and Arizona.
“The big opportunity for these is for health systems that want to establish a strong foothold in a really attractive market,” said Fred Bentley, a vice president at the Center for Payment & Delivery Innovation at Avalere Health. “If you’re an affluent consumer and you need services, they can fill a need.”
SCL Health has two microhospitals operating in the Denver metropolitan area and another two in the works. Microhospitals “are helping us deliver hospital services closer to home, and in a way that is more appropriately sized for the population compared to larger, more complex facilities,” said spokesman Brian Newsome.
The concept is appealing, and some people suggest they should be developed in rural or medically underserved areas where the need for services is great.
Small hospitals, even tiny ones, with robust outpatient services could be a real boon for people who live far from major metro areas.
“Right now they seem to be popping up in large urban and suburban metro areas,” said Priya Bathija, senior associate director for policy development at the American Hospital Association. However, “we really think they have the potential to help in vulnerable communities that have a lack of access.”
Analysts liken microhospitals to standalone emergency departments, which have been cropping up in recent years in fast-growing metropolitan areas where people are often well-insured and waits at regular hospital emergency departments may be long. Both can handle many emergencies and are equipped with lab, imaging and some diagnostic capabilities.
However, patients facing serious emergencies, such as severe chest pain or major medical trauma, should call 911 and let trained medical personnel decide where best to seek treatment, said Dr. Bret Nicks, an associate professor of emergency medicine at Wake Forest Baptist Health.
Unlike standalone EDs, microhospitals are fully licensed hospitals with inpatient beds to accommodate people admitted from the emergency room. They may have other capabilities as well, including surgical suites, a labor and delivery room, and primary care or specialist services on site or nearby.
Dignity Health, a health care system with facilities in Nevada, Arizona and California, opened its first microhospital in the Phoenix area more than a year ago and will open another one there this year, said Peggy Sanborn, vice president of strategic growth, mergers and acquisitions. It also plans to open four microhospitals in the Las Vegas area and is exploring the model for California.
One of the advantages of a microhospital is that it can help connect patients with specialty and primary care physician networks, said Sanborn. In Las Vegas, for example, the microhospital design includes a second floor with separate specialty and primary care physician offices to which patients could be referred.
The growing interest in microhospitals can be linked to the shift toward providing more care in outpatient settings, said Bathija. In addition to the emergency department, the facilities can include medical home services and other outpatient services.
Between 2010 and 2014, the annual number of inpatient hospital admissions declined by more than 2 million to 33.1 million, according to figures from the American Hospital Association. Meanwhile, the total number of outpatient hospital visits increased to 693.1 million in 2014 from 651.4 million four years earlier.
Microhospitals offer an opportunity to “really ramp up outpatient services,” Bathija said.
This week, the Journal of the American Medical Association (JAMA) published an article authored by President Barack Obama on his assessment of the Affordable Care Act (ACA). The article reviews the factors influencing the president’s decision to pursue health care reform, summarizes evidence on the effects of the law to date, recommends actions that could build on the progress made under the law to improve our health care system and identifies general lessons for current and future policymakers.
This article is the culmination of a review of the ACA’s performance that started more than six months ago at the president’s request, examining areas in which the law has been successful and in which it could be further strengthened to ensure all Americans have access to quality, affordable health care.
The president presents evidence in JAMA demonstrating the ways the law is working. This includes: sharply increasing insurance coverage and greatly improving coverage for those who already had it, which is improving Americans’ access to care, financial security, health and well-being; and shifting our health care system toward one that rewards doctors and hospitals for delivering efficient, high-quality care to patients, which has helped reduce hospital readmissions and deaths from hospital-acquired conditions and helped lower Medicare and private-sector health care spending.
Despite this significant progress, the president recognizes that more work is necessary to ensure every American can afford health care and navigate a complex health system. That’s why he offered five suggestions on how to do so:
Stay the course: Policymakers should build on the ACA’s successful framework by encouraging the remaining 19 states to expand Medicaid and continuing ongoing efforts to reform the health care delivery system, while maintaining bipartisan support for Precision Medicine, the BRAIN Initiative and the Cancer Moonshot.
Increase financial assistance to purchase health insurance: Because some individuals still report being unable to afford coverage, Congress should provide increased financial assistance to purchase coverage. The ACA’s coverage provisions are projected to cost 28 percent less than original Congressional Budget Office projections, providing an opportunity to reinvest these savings to make coverage even more affordable while keeping costs below initial projections.
Add a public plan option in areas of the country lacking competition: While the vast majority of Americans live in areas where there’s competition in the Health Insurance Marketplace, some parts of the country have long struggled with limited insurance market competition and continue to do so. That’s why the president urges Congress to revisit legislation to allow a public plan to compete alongside private insurers in areas of the country where competition is limited.
Address prescription drug costs: The increasing costs of prescription drugs are a major concern for Americans, employers, and taxpayers alike. Congress should act on proposals to lower the cost of prescription drugs, like the ones included in the president’s budget.
Avoid moving backward: The time spent by Republicans on more than 60 attempts to repeal parts of all of the ACA could have been better spent working to improve our health care system and economy.
Finally, the president offers some lessons to current and future policymakers that he learned from his experience: that any change is difficult, especially when facing hyperpartisanship; that special interests pose a continued obstacle and we must continue to tackle them, and that pragmatism is of the utmost importance in both legislation and implementation. But most importantly, that the president’s experience with the ACA makes him optimistic about America’s capacity to make meaningful progress on even the biggest public policy challenges. As progress on health care reform demonstrates, faith in responsibility, belief in opportunity and ability to unite around common values are what make this nation great.
The movie “Independence Day” came out 20 years ago and was a huge box office success. In one of the longest sequel gaps in movie history, “Independence Day: Resurgence” is now on the big screen. While the show promises to be great summer entertainment, one critic has asked why the entertainment industry seems to continually revisit the same old stories…is there nothing new under the Hollywood sun?
With a little reflection, the same can be said about the state of our health care system. Last week, the U.S. House of Representatives released its long-awaited alternative plan to Obamacare. It includes such things as more health savings accounts, medical malpractice reforms, purchasing insurance across state lines and greater use of wellness programs. Gee…haven’t we “been there, done that”? And without any experience or evidence to prove these concepts lower the health care cost curve or actually provide meaningful health care access to real people? We didn’t like those “shows” before; these sequels would likely be no more fulfilling.
We’re not immune from health care “repeats” in Iowa, either. Currently there are some corners of the state calling for a review of Iowa’s certificate of need (CON) laws. Even the governor has recently been somewhat critical of the program, despite the fact that he approved significant changes to CON in the late 1990s that modeled the program into what it is today and it’s his office that names people to the Health Facilities Council (the board that approves CON applications). These recent criticisms are at least the third time in the past two decades that CON has come under fire, despite real evidence that states with CON statutes have lower health care costs and less intensive health care infrastructure. Same old, same old.
And of course, Iowa’s recent entry into Medicaid managed care continues this pattern of repetition. In Kansas, Connecticut, Florida, California and other states, hospitals and other providers have learned that managed care promises much but ultimately fails to deliver new or transformative ideas. Now, as expected, Iowa is screening the sequel to this theater of the absurd.
IHA continues to hear that claims aren’t being paid (or are being paid at ridiculously incorrect amounts), prior authorization denials are soaring and patients are challenged to get the services they need. Nothing new, just finding ways of not paying for care. A re-visitation of the failed HMO “gatekeeper” philosophy from 20 years ago.
Where are the new ideas in health care? In Iowa, those can be found at the provider level. Whether we’re talking the development of Accountable Care Organizations and population health initiatives or the hospital-led community health improvements through the State Innovation Model projects, Iowa hospitals are leading the way toward innovative care strategies and future payment reform. But just as Hollywood producers are gunning for the box office “sure thing,” so are our policymakers turning a deaf ear to the future while embracing failed health policy reforms of the past.
At least if you don’t like “Independence Day 2,” you can just leave the theater.
Some people receive constant reminders on their personal smartphones: birthdays, anniversaries, doctor’s appointments, social engagements. At work, their computers prompt them to meet deadlines, attend meetings and have lunch with the boss. Prodding here and pinging there, these pop-up interruptions can turn into noise to be ignored instead of helpful nudges.
Something similar is happening to doctors, nurses and pharmacists. And when they’re hit with too much information, the result can be a health hazard. The electronic patient records that the federal government has been pushing — in an effort to coordinate health care and reduce mistakes — come with a host of bells and whistles that may be doing the opposite in some cases.
What’s the problem? It’s called alert fatigue.
Electronic health records (EHRs) increasingly include automated alert systems pegged to patients’ health information. One alert might signal that a drug being prescribed could interact badly with other medications. Another might advise the pharmacist about a patient’s drug allergy. But they could also simply note each time that a patient is prescribed painkillers — useful to detect addiction but irrelevant if, say, someone had a major surgery and is expected to need such meds. Or they may highlight a potential health consequence relevant to an elderly woman, although the patient at hand is a 20-something man.
The number of these pop-up messages has become unmanageable, doctors and IT experts say, reflecting what many experts call excessive caution, and now they are overwhelming practitioners.
Clinicians ignore safety notifications between 49 percent and 96 percent of the time, said Shobha Phansalkar, an assistant professor of medicine at Harvard Medical School.
“When providers are bombarded with warnings, they will predictably miss important things,” said David Bates, senior vice president at Brigham and Women’s Hospital in Boston.
Now, doctors, health information technologists and software vendors are trying to fix the problem.
Research on this human-computer interaction is starting to explore the degree of risk posed by excessive alerting versus the benefits the alerts produce. The companies selling electronic health records say advances are moving their systems toward more targeted, relevant warnings, instead of broad-brush signaling.
“This is an issue that everyone’s going to have to wrestle with eventually,” said Bill Marella, executive director of patient safety operations and analytics at ECRI Institute, a nonprofit organization that studies health care safety and quality issues. In April, the institute ranked design and implementation of new health IT systems as its top safety concern for 2016.
Some hospitals and health systems are already paving the way.
Take Children’s Hospital of Philadelphia. In 2012, the inpatient facility switched over to a new electronic health record, said Eric Shelov, a physician and the hospital’s associate chief medical information officer. Immediately, he said, practitioners began seeing far more alerts, to the point that doctors were overriding almost all of them. The problem, Shelov said, is that “if you see enough nonsense, you’re going to start ignoring it.”
That has consequences. In one instance at Children’s, doctors ignored relevant information about how a patient might respond to a drug, Shelov said, because it appeared alongside heaps of other superfluous notifications — warnings, for instance, about drugs that posed minimal risk of interfering with each other. Consequently, the patient received medication that induced a potentially lethal reaction.
The hospital caught the mistake in time, but the incident spurred a series of changes. A team of pharmacists, doctors and other clinicians have sorted through what triggered alerts in their system, turning off the ones they decided weren’t actually relevant or necessary. That has helped. But it’s still an ongoing battle, Shelov said. “It’s a little bit of trying to turn off the firehose.”
Systems such as Cleveland-based MetroHealth, the University of Vermont Medical Center and Group Health Collaborative of Southern Wisconsin have undertaken similar projects. Still others, like Brigham and Women’s, are working on it.
But figuring out what merits a computer warning takes time, manpower, expertise and money. Not all hospitals have those resources, Bates said. It’s inherently subjective. Some stakeholder groups have put out recommendations, and hospitals like Children’s have presented on ways to combat alert fatigue. But individual hospital task forces often end up deciding for themselves what’s risky enough to warrant an alert.
Patients, meanwhile, aren’t standing beside their doctors as they scroll through their medical records, noted Helen Haskell, a patient safety advocate. Patients can request access to their records, but that’s a static page they’ll see only after getting care. That means that, while this hyper-alerting poses a danger, there’s no way for consumers to know if, say, they got worse care because the doctor missed a warning.
“It’s very rare that patients are granted that perspective,” she said.
Software vendors say they’re trying to make their systems smarter.
Epic Systems, outside Madison, Wisconsin, for example, has been hearing feedback for years from doctors about redundant or irrelevant alerts, said Bret Shillingstad, a physician who works on Epic’s clinical informatics team. They’ve added in functionality for hospitals to turn those alerts off. They’re working now to develop software that might target alerts based on things like a patient’s health condition or recommend medications that better match someone’s overall profile. Then there are simpler adjustments, like changing a system so that if a patient needs a vaccine, reminders just go to the primary care doctor, not the orthopedist, too.
In the long term, system designers are trying to better consider the nuances of a patient’s medical needs so that they can use fewer warnings and send them only when they matter, said Terry Fairbanks, an emergency physician and director of MedStar Health’s National Center for Human Factors in Healthcare in Washington, D.C. For instance, people with advanced cancer often need doses of morphine that might be unsuitable for other patients. A smarter system would warn doctors about that morphine order for patients who don’t have cancer but would treat it as normal for someone in the disease’s late stages.
Such a change could limit distractions so that physicians act upon pressing reminders — like notifications highlighting if a patient is at risk for sepsis, which can be deadly if it’s not noticed early.
But there’s still debate. Haskell said she would argue doctors should always be warned about certain medications and drug interactions.
“All of these alerts have really reduced medication interactions. It’s a service,” she said. “It just needs to be refined.”
But there’s clearly a cultural shift underfoot, added Phansalkar, who also works as director of informatics and clinical innovation at Wolters Kluwer Health, which supplies drug information to electronic health record systems. Alert fatigue is no longer “just something providers complain about,” she said. In health care, people are trying to devise more effective, nuanced ways for electronic systems to improve care.
“Because it’s so easy to put an alert to address a problem, that’s people’s natural, knee-jerk reaction,” said Douglas Gentile, medical director of clinical information systems at the University of Vermont Medical Center. But “as you add those, it creates additional problems. And you get collateral damage.”
Owen had been living outside for many years. He suffered an injury to his back and neck about 20 years ago. He wasn’t able to work and support himself after that. He was proud of how he cared for his campsite and liked living outdoors. But there were two big problems: The city was shutting down the camp and his physical health was deteriorating. He didn’t know if he could survive another Iowa winter outside, especially if he had to move.
Fortunately, he connected with a local hospital and a trusting relationship was built. He was enrolled in health insurance and qualified for disability benefits under Social Security. Despite early apprehension, he started showing up to medical appointments and received consistent care.
The hospital also helped him find an apartment, set up a bank account and get a phone. Now Owen’s life is stabilizing, he enjoys making meals in his apartment and is optimistic about his future.
Robert was staying at the local shelter when he was referred to the hospital. In the years prior, he had lost his job and gone through a bad divorce. As a result, he had no stable place to live and no money. He was very depressed.
The hospital assisted Robert in finding an apartment and secured rent support for him. Once Robert obtained stable housing, the hospital referred him to Goodwill’s supportive employment services. Robert was interested in their janitorial training program and he excelled right away.
About the time Robert completed the janitorial program, Goodwill moved to a new building. He was hired as a fulltime overnight janitor. He shared the good news with the people at the hospital who had helped him. He said he couldn’t remember the last time he felt so happy.
These are two true stories about Iowans in need and how a hospital intervened and served them, not with groundbreaking research, intricate surgery or amazing technology, but with those things that hospitals and the people who work for them have been bringing to the table for centuries: compassion, dedication, hope, resourcefulness. Such are the roots of community-based health care, but it is also where health care is headed.
Every day brings greater understanding about how an individual’s world affects their health. Not only the world where they live today, but the one where they grew up, went to school and where they work now and before. Health by definition is the absence of disease or injury, but that is just a fleeting snapshot, an ever-changing sum of a hundred different inputs.
The provision of “health care” is a relatively small determinant of overall health – perhaps 10 percent, most experts agree. To truly meet the Triple Aim, hospitals and other providers must participate and lead in the other 90 percent. Those opportunities are found in shelters for the homeless and abused. In daycares, schools, neighborhoods, parks and recreation centers. In VFW halls and senior centers. In factories, offices and farm fields. In courtrooms and the places of government.
These are the places where health and lives, like Owen’s and Robert’s, will be lost or saved. And to truly make a difference, hospitals must be there too.
That is the legacy of community-based health care – and its future.