For hospitals, health reform starts today

The start of October means, for most Americans, the onset of chilly weather and a chance to start thinking up a new Halloween costume. For budget wonks, it signifies the start of a new fiscal year.

And for American hospitals, it means something quite different: October 1 is arguably the day that the health reform law changed the way they get paid for providing health care.

There are two big parts of the health reform law going into effect today. One penalizes hospitals if patients are re-admitted to the hospital within one month of a visit for a condition that should have been dealt with on the first trip. The other seeks to redistribute higher Medicare payments to the hospitals that are delivering better care.

Both are part of an effort to fundamentally transform the health-care system in the United States by moving it from a system that pays for value rather than volume. If efforts like these succeed, hospitals will become more concerned with delivering higher quality health care. If they don’t, health providers will continue to earn a living the way they have for decades: By earning a fee for every service they deliver.

Let’s break down how these two programs work a bit more. The first one cuts payments to hospitals for preventable re-admissions in Medicare. That’s when a senior turns up at a hospital within one month of a previous visit with a problem that should have been dealt with on their first visit — or, perhaps, was caused by that first visit.

This happens a lot: The independent Medicare Payment Advisory Commission estimates that 15.3 percent of hospital admissions result in a re-admission. In 2010 alone, this happened 1.9 million times at an estimated cost of $17.5 billion.

Until now, there weren’t much in the way of penalties for a patient landing back in the hospital. There was actually a financial incentive for readmitting a patient, as that would mean delivering more health care that they could bill for.

That calculus changes today. Hospitals now stand to lose as much as 1 percent of their reimbursement rate if their patient lands back in a hospital bed within weeks. All of a sudden, bad care isn’t just bad for the patient — it’s bad for the hospital’s bottom line. To achieve full reimbursement rates, hospitals are going to have to work at keeping patients healthy enough to stay out of their facilities altogether.

That’s the first program. The second one, called Value Based Purchasing, also looks to nudge hospitals to delivering higher-quality care.

It begins with the federal government withholding 1 percent of payments to about 3,000 hospitals that deliver acute care. That money goes into a sort of pool, with about $850 million at stake. The hospitals that do well on certain quality metrics will get paid even more out of the pool than they put in — in other words, they get a raise. Those that do poorly on quality may not get anything back out of the pool — they deserve a rate cut, the thinking goes, because they are not delivering high-enough-quality care.

Again, the goal is to create an incentive for hospitals to deliver high-quality care, rather than perform lots and lots of procedures. The program will become more aggressive in 2013, when hospitals will see 2 percent of their reimbursements withheld for these quality bonuses.

There are questions about whether these payment shifts are enough to change hospitals’  behavior. With the re-admissions program, for example, we’re only talking about $300 million of the $140 billion spent on Medicare hospital visits annually, or 0.2 percent. Is that enough to catalyze change?

My colleague Lena Sun talked to a number of hospitals in the Washington area and found some pretty strong evidence that, yes, it was indeed strong enough:

"In Northern Virginia, the Inova health system has spent $2.4 million to hire eight health coaches and four case managers to coordinate and keep track of patients after discharge, said Vera Dvorak, vice president for transitional care. The company also opened two special clinics where doctors see Inova patients who can’t get appointments with their regular providers within a week after discharge. Inova’s five hospitals will get paid about $250,000 less from Medicare this coming year because of the penalties, officials said.

Even hospitals that were not penalized have taken steps.

Virginia Hospital Center opened a pharmacy on its campus and launched its own home health service. The penalty, said Robin Norman, chief financial officer, “is enough to have every hospital’s attention.”

We’re on day one of this program right now, so it’s pretty difficult to tell what this will mean for the health-care system — whether hospitals will act like Inova, and retool around the new programs, or decide to take a small hit rather than make a big investment.

We’ll learn more in the coming year about whether the health law can change how care gets delivered — or whether we continue to stick with the status quo.

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Health care ruling a victory, says Dignity CEO

"Life," said Lloyd Dean, CEO of Dignity Health, "is not too bad today."

Dean, a strong supporter of President Obama and a longtime advocate of universal health insurance, said Thursday's Supreme Court ruling was "a victory for patient care, and for those underserved by the health care system."

He had initially been skeptical of Obama's one-fell-swoop approach, telling The Chronicle in 2008 "some incremental steps" might be best, given the exigencies of the Great Recession. "There are not the resources available we could have hoped for," said Dean, who was on the short list to be Obama's secretary of health and human services.

Dean soon came around to the administration's thinking, but says the fight is not over. "The current law is not perfect. We need to fix the elements that people have had difficulties with." In particular, costs. "Although the act begins to bend the cost curve, we have to address how we're going to pay for what we are planning to deliver," he said.

"We have to find a way to deliver quality health care services in a cost-effective manner. That means people only be admitted to hospitals who really need to be in a hospital. That there is more focus on preventative care, that chronic conditions get treated early, before they become acute."

Dignity Health (formerly Catholic Healthcare West), headquartered in San Francisco, is the fifth-largest hospital chain in the country, with 40 full-service hospitals in California, Arizona and Nevada, and 150 ancillary clinics. It's one of 26 hospitals nationwide chosen byMedicare for a pilot program, funded by the Patient Protection and Affordable Care Act, to try to reduce the high rate of health complications and hospital readmissions (and high costs) among elderly patients.

While profitable, the company, which recorded $10.6 billion in revenue last year, is "burdened" by low reimbursements from a large number of Medicaid patients, and the low-cost or free medical services it provides, according to a Standard and Poor's report.

Reductions in Medicare reimbursements to hospitals, as provided in the act, might not make life any easier. Still, said Dean, "we supported this legislation, even though it reduces payments to hospitals, because the new delivery model it creates focuses on reducing costs by increasing the quality of care."

But, he said, "it doesn't get us off the agenda of being a more cost effective, higher quality provider of service."

"Hopefully," he added, referring to the Supreme Court's ruling, "we have enough stability and momentum to address the issues that need to be fixed."

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Poll: What It's Like To Be Sick In America

In the lull between the Supreme Court arguments over the federal health overhaul law and the decision expected in June, we thought we'd ask Americans who actually use the health system quite a bit how they view the quality of care and its cost.

Most surveys don't break it down this way.

When the results came back, we found that people who have a serious medical condition or who've been in the hospital in the past year tended to have more concerns about costs and quality than people who aren't sick. No big surprise there.

But what was notable: 3 of 4 people who were sick said cost is a very serious problem, and half said quality is a very serious problem.

Nearly half of those with recent serious illness say they felt burdened by what they had to pay out of their own pocket for care.

The recently ill are more likely to say the cost and quality of care have worsened over the past five years, compared to people who weren't sick.

Among people who've recently required a lot of care, significant proportions say their treatment was poorly managed, with nearly a third complaining of poor communication among their caregivers. One in eight believe they got the wrong diagnosis, treatment or test.

Compared to the not sick people in our poll, Americans who've been sick in the past 12 months ...

Source: NPR/Robert Wood Johnson Foundation/Harvard School of Public Health Poll
Credit: Alyson Hurt/Nelson Hsu, NPR

Those findings led us to investigate the problems people are having, both in our poll and in a series of stories on the radio and the Web we're calling "Sick in America."

The poll, a joint venture of NPR, the Robert Wood Johnson Foundation and the Harvard School of Public Health, is one of very few focusing on people who've actually been seriously ill, injured or hospitalized in the past year.

"This poll listens to the voices of the sick," says Robert Blendon of Harvard. "That provides a good barometer of what's happening in health care in America."

The poll randomly surveyed 1,508 adults across the nation. A little more than a quarter of them had a serious illness, injury or disability requiring "a lot of medical care," or overnight hospitalization within the past 12 months.

If you want to dive deeper, here's a summary of the poll findings, plus the topline data and charts. And you can meet some of the real people who shared their experiences of being sick in America with NPR in this post.

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Measuring quality improves doctors' care, study finds

Wisconsin collaborative says disclosing rankings pushes doctors to try harder

The Wisconsin Collaborative for Healthcare Quality was founded on a simple premise: To improve the quality of health care, you must be able to measure it.

It is one of the underlying principles in the efforts to provide better care to patients.

Yet the premise that tracking the quality of care truly prods physicians to change the way they practice medicine has been more accepted than studied.

The Wisconsin Collaborative for Healthcare Quality, started by a group of large physician practices and health care systems in 2003, now can be cited as an example that it does.

A study led by Geoffrey Lamb, a professor at the Medical College of Wisconsin, compared the care given to diabetic patients by physician practices that belong to the collaborative with the care given by physicians in Iowa and South Dakota as well as national performance measures.

The study found that the collaborative's members improved overall in every measure, such as monitoring a diabetes patient's kidney function, which was tracked for more than two years.

"These were changes that really impacted a lot of people," said Lamb, associate director of the Joint Quality Office of the Medical College of Wisconsin and Froedtert Hospital.

"The thing that really impressed me is the people who performed the lowest when they started had the greatest improvement," he said. "They cared where they were in ranking."

That gives additional credence to the long-standing contention that publicly disclosing how doctors perform on various measures of health care quality can result in better care.

"Transparency matters," said Christopher Queram, president and chief executive of the collaborative.

The study was funded by a $295,889 grant from the Commonwealth Fund, a private foundation that supports independent research on health care and health policy.

Numerous studies have been done on the quality measures and outcomes now tracked and reported by hospitals. The amount of information available on the Hospital Compare website, www.hospitalcompare.hhs.gov, which can be found on Medicare's website, has grown each year.

Examining the physicians

But relatively little information is available about the quality of care provided by doctors in their offices.

"Depending on where you live in the country, it's hard to get good data," said Anne Marie Audet, a physician and vice president for health system quality and efficiency at the Commonwealth Fund.

The collaborative was one of the few organizations with quality information for physician practices.

The group, which has drawn national attention for its work, now tracks more than 30 quality measures for physician practices. And one of the goals of the study was to show the value in gathering and disclosing the information.

"Our hope is this will help accelerate the acceptance by physicians," Queram said.

One challenge is that few accepted quality measures exist for specialty care, with the exception of cardiology. Better measures also need to be developed to track the coordination of care, an area where the health system often falls short.

"It is a work in progress," Audet said.

Quality of care

That work will be essential, though, if the country is to get more value from the money it spends on health care.

Federal health care reform allocates $10 billion over 10 years to test new ways of paying doctors and hospitals and delivering care. Broad support exists for moving toward paying doctors and hospitals for the quality of care they provide rather than for specific services. But that will require developing better ways to gauge the quality of care.

The National Quality Forum has endorsed more than 500 standards for tracking health care quality and performance over the past decade. But significant gaps still exist, including such thorny tasks as measuring the accuracy of diagnoses, surgical success rates and the appropriateness of diagnostic tests and procedures. And in some cases, some measures may not result in better outcomes.

Developing better and more standard measures will take time, Audet said. "But it's important to have a strategy," she said.

Disclosure matters

The study on the collaborative also suggests that each new measure can lead to better care.

Lamb and the other investigators in the study found that doctors were more likely to follow guidelines and to contact patients due for tests once their performance was publicly reported.

The study's other investigators were Maureen Smith, a physician and professor at the University of Wisconsin School of Medicine and Public Health; Williams Weeks, a physician at the Dartmouth Institute for Health Policy and Clinical Practice; and Queram.

Taking action

The study isn't flawless. For one thing, the physician practices that belong to the collaborative may not be representative. Nearly all of them, for example, now have electronic health records. That enabled the practices to track patients due for visits and eased the task of following their performance.

The study included a survey on what steps the physician practices took once the information on their performance was published.

Lamb saw that firsthand at the Medical College of Wisconsin.

When the medical school first provided information to the collaborative on how its physicians cared for diabetes patients, Lamb had a new position and only had a few weeks to pull together the information.

The information wasn't gathered properly, he said, and the results were less than stellar.

"The effort that went into improving their performance over the coming year really was quite dramatic," Lamb said. "They didn't like looking bad."

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Study Finds No Progress in Safety at Hospitals

Efforts to make hospitals safer for patients are falling short, researchers report in the first large study in a decade to analyze harm from medical care and to track it over time.

The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections.

“It is unlikely that other regions of the country have fared better,” said Dr. Christopher P. Landrigan, the lead author of the study and an assistant professor at Harvard Medical School. The study is being published on Thursday in The New England Journal of Medicine.


It is one of the most rigorous efforts to collect data about patient safety since a landmark report in 1999 found that medical mistakes caused as many as 98,000 deaths and more than one million injuries a year in the United States. That report, by the Institute of Medicine, an independent group that advises the government on health matters, led to a national movement to reduce errors and make hospital stays less hazardous to patients’ health.

Among the preventable problems that Dr. Landrigan’s team identified were severe bleeding during an operation, serious breathing trouble caused by a procedure that was performed incorrectly, a fall that dislocated a patient’s hip and damaged a nerve, and vaginal cuts caused by a vacuum device used to help deliver a baby.

Dr. Landrigan’s team focused on North Carolina because its hospitals, compared with those in most states, have been more involved in programs to improve patient safety.

But instead of improvements, the researchers found a high rate of problems. About 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few — 2.4 percent — caused or contributed to a patient’s death, the study found.

The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the hospitals’ failure to use measures that had been proved to avert mistakes and to prevent infections from devices like urinary catheters, ventilators and lines inserted into veins and arteries.

“Until there is a more coordinated effort to implement those strategies proven beneficial, I think that progress in patient safety will be very slow,” he said.

An expert on hospital safety who was not associated with the study said the findings were a warning for the patient-safety movement. “We need to do more, and to do it more quickly,” said the expert, Dr. Robert M. Wachter, the chief of hospital medicine at the University of California, San Francisco.

A recent government report found similar results, saying that in October 2008, 13.5 percent of Medicare beneficiaries — 134,000 patients — experienced “adverse events” during hospital stays. The report said the extra treatment required as a result of the injuries could cost Medicare several billion dollars a year. And in 1.5 percent of the patients — 15,000 in the month studied — medical mistakes contributed to their deaths. That report, issued this month by the inspector general of the Department of Health and Human Services, was based on a sample of Medicare records from patients discharged from hospitals.

Dr. Landrigan’s study reviewed the records of 2,341 patients admitted to 10 hospitals — in both urban and rural areas and involving large and small medical centers. (The hospitals were not named.) The researchers used a “trigger tool,” a list of 54 red flags that indicated something could have gone wrong. They included drugs used only to reverse an overdose, the presence of bedsores or the patient’s readmission to the hospital within 30 days.

The researchers found 588 instances in which a patient was harmed by medical care, or 25.1 injuries per 100 admissions.

Not all the problems were serious. Most were temporary and treatable, like a bout with severe low blood sugar from receiving too much insulin or a urinary infection caused by a catheter. But 42.7 percent of them required extra time in the hospital for treatment of problems like an infected surgical incision.

In 2.9 percent of the cases, patients suffered a permanent injury — brain damage from a stroke that could have been prevented after an operation, for example. A little more than 8 percent of the problems were life-threatening, like severe bleeding during surgery. And 2.4 percent of them caused or contributed to a patient’s death — like bleeding and organ failure after surgery.

Medication errors caused problems in 162 cases. Computerized systems for ordering drugs can cut such mistakes by up to 80 percent, Dr. Landrigan said. But only 17 percent of hospitals have such systems.

For the most part, the reporting of medical errors or harm to patients is voluntary, and that “vastly underestimates the frequency of errors and injuries that occur,” Dr. Landrigan said.

“We need a monitoring system that is mandatory,” he said. “There has to be some mechanism for federal-level reporting, where hospitals across the country are held to it.”

Dr. Mark R. Chassin, president of the Joint Commission, which accredits hospitals, cautioned that the study was limited by its list of “triggers.” If a hospital had performed a completely unnecessary operation, but had done it well, the study would not have uncovered it, he said. Similarly, he said, the study would not have found areas where many hospitals have made progress, such as in making sure that patients who had heart attacks or heart failure were sent home with the right medicines.

The bottom line, he said, “is that preventable complications are way too frequent in American health care, and “it’s not a problem we’re going to get rid of in six months or a year.”

Dr. Wachter said the study made clear the difficulty in improving patients’ safety.

“Process changes, like a new computer system or the use of a checklist, may help a bit,” he said, “but if they are not embedded in a system in which the providers are engaged in safety efforts, educated about how to identify safety hazards and fix them, and have a culture of strong communication and teamwork, progress may be painfully slow.”

Leah Binder, the chief executive officer of the Leapfrog Group, a patient safety organization whose members include large employers trying to improve health care, said it was essential that hospitals be more open about reporting problems.

“What we know works in a general sense is a competitive open market where consumers can compare providers and services,” she said. “Right now you ought to be able to know the infection rate of every hospital in your community.”

For hospitals with poor scores, there should be consequences, Ms. Binder said: “And the consequences need to be the feet of the American public.”

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Life Expectancy vs. Health Care Spending

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Healthcare around the world (BBC)

United States - Private system

Private sector funded, with more than half from private sources. Private health insurance available through employer, government or private schemes.

15.3% of population (45.7 million people) do not have health insurance.

Federal government is largest health care insurer - involved in two main schemes, Medicaid and Medicare, each covering about 13% of population.

Medicaid - joint funded federal-state programme for certain low income and needy groups - eg children, disabled.

Medicare - for people 65 years old and above and some younger disabled people and those with permanent kidney failure undergoing dialysis or transplant.

Most doctors are in private practice and paid through combination of charges, discounted fees paid by private health plans, public programmes, and direct patient fees.

In-patient care is provided in public and private hospitals. Hospitals are paid through a combination of charges, per admission, and capitation.

United Kingdom - Universal, tax-funded system

Public sector funded by taxation and some national insurance contributions.

About 11% have private health insurance. Private GP services very small.

Health care free at point of delivery but charges for prescription drugs, ophthalmic services and dental services unless exempt.

Exemptions include children, elderly, and unemployed. About 85% of prescriptions are exempt.

Most walk-in care provided by GP practices but also some walk-in clinics and 24-hour NHS telephone helpline. Free ambulance service and access to accident and emergency. In patient care through GP referral and followcontractual arrangements between health authorities, Primary Care Trusts and the hospital.

Hospitals are semi-autonomous self-governing public trusts.

France - Social insurance system

All legal residents covered by public health insurance funded by compulsory social health insurance contributions from employers and employees with no option to opt out.

Most people have extra private insurance to cover areas that are not eligible for reimbursement by the public health insurance system and many make out of pocket payments to see a doctor.

Patients pay doctor's bills and are reimbursed by sickness insurance funds.

Government regulates contribution rates paid to sickness funds, sets global budgets and salaries for public hospitals.

In-patient care is provided in public and private hospitals (not-for-profit and for-profit). Doctors in public hospitals are salaried whilst those in private hospitals are paid on a fee-for-service basis. Some public hospital doctors are allowed to treat private patients in the hospital. A percentage of the private fee is payable to the hospital.

Most out-patient care is delivered by doctors, dentists and medical auxiliaries working in their own practices.

Singapore - Dual system

Dual system funded by private and public sectors. Public sector provides 80% of hospital care 20% primary care.

Financed by combination of taxes, employee medical benefits, compulsory savings in the form of Medisave, insurance and out-of-pocket payments.

Patients expected to pay part of their medical expenses and to pay more for higher level of service. Government subsidises basic healthcare.

Public sector health services cater for lower income groups who cannot afford private sector charges. In private hospitals and outpatient clinics, patients pay the amount charged by the hospitals and doctors on a fee-for-service basis.

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2008 International Health Policy Survey

In Chronic Condition: Experiences of Patients with Complex Health Care Needs, in Eight Countries Charts - (25 charts)

This chart shows that there is a serious problem with access to care for people in the US with chronic conditions.

Experts say U.S. healthcare wasteful

Top healthcare executives say the U.S. medical system is wasteful, inefficient and not giving people their money's worth.

"We're not getting what we pay for," said Denis Cortese, president and chief executive of the Mayo Clinic. "It's just that simple."

Cortese and other healthcare executives estimate as much as half of the $2.3 trillion spent annually on medical care does nothing to improve health, The Washington Post reported Sunday.

An improved healthcare system would revolve around paying for results, which means managing chronic illnesses better, realigning financial incentives to reward success, encouraging disease prevention and rejecting costly, unproven therapies, healthcare providers told the post.

The United States devotes 16 percent of its gross domestic product to medical care -- more per capita than any other nation -- yet ranks 29th in infant mortality and 48th in life expectancy among industrialized nations, the Post reported.

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Death Rate 70 Percent Lower At Top-rated Hospitals: HealthGrades Annual Hospital Quality Study

Patients have on average a 70 percent lower chance of dying at the nation's top-rated hospitals compared with the lowest-rated hospitals across 17 procedures and conditions analyzed in the eleventh annual HealthGrades Hospital Quality in America Study, recently issued by HealthGrades, the leading independent healthcare ratings organization.

While overall death rates declined from 2005 to 2007, the nation's best-performing hospitals were able to reduce their death rates at a much faster rate than poorly performing hospitals, resulting in large state, regional and hospital-to-hospital variations in the quality of patient care, the study found.

HealthGrades Hospital Quality in America Study, also found that if all hospitals performed at the level of five-star rated hospitals, 237,420 Medicare deaths could potentially have been prevented over the three years studied. More than half of those deaths were associated with four conditions: sepsis (a life-threatening illness caused by systemic response to infection), pneumonia, heart failure and respiratory failure.

The HealthGrades study of patient outcomes at the nation's approximately 5,000 hospitals is the most comprehensive annual study of its kind, analyzing more than 41 million Medicare hospitalization records from 2005 to 2007. The study examines procedures and conditions ranging from heart valve-replacement surgery to heart attack to pneumonia.

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US healthcare costs more, delivers less: study

The United States lags behind other industrialized nations in the quality of its healthcare despite having the costliest system in the world, according to a report released on Thursday.

The US healthcare system is plagued by inefficiency, inequality and an incoherent national policy, said the report from the private Commonwealth Fund foundation.

"The US spends twice per capita what other major industrialized countries spend on health care, and costs continue to rise faster than income," said the report.

"We should expect a better return on this investment."

The foundation used a 100-point scorecard to rate the system based on 37 categories, including access to health care, quality of care and efficiency.

The US average came to 65, two points down from a previous measure in 2006. The score is compared to other countries and the best performing US states, counties or hospitals.

The measures showed "that the US is losing ground in providing access to care and has uneven health care quality" and also revealed "broad evidence of inefficient and inequitable care," it said.

The United States ranked last among 19 industrialized states when it comes to preventing premature deaths from conditions such as heart attacks that can be treated with timely, effective care, the report said.

Up to 101,000 less people would die prematurely if the US achieved the lower mortality rates of top performing countries such as France or Japan, it said.

Infant mortality rates also remain high in the United States compared to other industrialized nations.

Access to health care was on the decline, with more Americans without health insurance or without adequate insurance. In 2007, 75 million working-age adults were either uninsured or underinsured, up from 61 million in 2003.

Americans reported more delays in securing appointments with doctors. "In 2007, as in 2005, less than half of US adults with health problems were able to get a rapid appointment with a physician when they were sick," it said.

The US scored poorly on efficiency, with patients subjected to duplicate tests, unnecessary hospital admissions, high administrative costs and outdated record keeping, it said.

Only 28 percent of US doctors use electronic medical records, compared to nearly 100 percent in leading countries.

The report, based on data from US government agencies and other sources, underlined some areas of progress, including improved safety at hospitals and better control of diabetes and high blood pressure.

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Cash-for-quality in new-look NHS

By Caroline Parkinson
BBC News health reporter

This is no ordinary health service. This is a top-quality health service.

Or at least that's what the government hopes people will think after its latest review of the NHS.

Lord Darzi's plan for the next 10 years of the health service in England does not set doctors and nurses new targets, nor does it call for wholesale reorganisation of the way services are delivered - as previous reviews have done.

What it does do is emphasise the importance of striving for high quality care, wherever and however a patient is using the NHS.

Hospital and GP practice funding will, for the first time, be partially linked to how good patients think their care has been - with their whole experience being measured.

These views will be made public on the web and on clinical "dashboards" in hospitals and surgeries, so patients will be able to make informed choices about where they go for their care.

Ministers believe that making the link between quality and funding, and offering patients greater choice will lead to improvements, as providers seek to avoid missing out on patients and therefore money.

As Lord Darzi said when he launched his review, the aim is to give patients "more clout".

Once in a generation?

A draft NHS Constitution published alongside the review sets out the rights of patients, such as greater choice of GP and the right to drugs approved by the NHS watchdog - as well as responsibilities such as taking part in vaccination schemes and abiding by treatment plans given by their doctors.

The response to the plans has been overwhelmingly positive, with commentators praising the amount of consultation with front-line NHS staff and patients.

Sir Ian Kennedy, chair of the Healthcare Commission said: "The proposals should be given a fair wind - they deserve one."

The King's Fund, the independent think-tank, said the review was "good news" for patients because it did not go against the grain of the way the health service was already operating.

But it warned it would be hard for it to live up to its "once in a generation" billing.

Chief executive Niall Dickson called the report a "sensible set of measures".

But he said: "The big test will be to make it a reality."

The King's Fund warns there are no estimates about how much the proposals in the review will cost, or how different the quality of services will be in five or 10 years time.

And Sir Ian Kennedy warned the Darzi review was short on detail about how performance against quality standards would be independently assessed.

'Let go'

The drafting of an NHS Constitution was welcomed, with Niall Dickson saying it would help people take greater contol of their healthcare through having more information and the Patients Association's Sally Brearley said it could be a "valuable and powerful document in the hands of patients to help them get the best quality care".

But there has been critism that the review does not go far enough in offering clinicians over how care is provided locally.

Doctors say the government still has not been able to "let go" enough.

The British Medical Association's Mark Porter said it was still not allowing clinicians and hospitals to focus on local priorities, and was still imposing "top-down targets".

Opposition parties also said the review still failed to recognise the need for Whitehall to "stop interfering" and end its micromanagement of the service, while the Liberal Democrats said that when the dust had settled, people would realise "the system of command and control diktat by Whitehall" lived on.

BBC News

Insured losing access to healthcare: U.S. study

WASHINGTON (AFP) — Nearly half of Americans are saving less, and nearly a quarter have reined in their spending on food and healthcare as soaring petrol prices bite into household budgets, a survey showed Thursday.

"Forty-five percent of respondents have been putting less money into savings accounts; 24 percent have cut back on essentials like food or healthcare; and 17 percent have charged more expenses on credit cards -- all troubling trends," according to the Auto Pulse survey, conducted by the Consumer Reports National Research Center.

Nearly a third of the 884 people polled earlier this month said they are walking or riding bicycles more to save money, and 16 percent said they are using public transportation more, said the poll, which was conducted as petrol prices climbed above the four-dollar mark.

"In the 2007 Auto Pulse survey on gas prices, Consumer Reports found the tipping point at which motorists said they would drastically reduce driving would be 3.50 dollars," a report accompanying the survey said.

"And they have. Year to date, 20 billion fewer miles have been traveled compared to 2007 for the same period," the report said, citing Department of Transportation data.

The new "tipping point" would come when petrol hits 4.32 dollars per gallon, the report said.

That was only 24 cents higher than the national average earlier this week, it said, and indicated that Americans have "less flexibility in their budgets" this year compared to last.

More than three quarters of Americans blame botched government policies for record high petrol prices, and nine in 10 favor developing alternative energy sources as a way out of the crisis, according to the survey.

Petrol prices have climbed nearly 40 percent since February, when a gallon of gas cost 2.96 dollars. On Monday, a gallon cost 4.08 dollars, the report said, citing data from the Energy Information Administration.

Seventy-five percent of Americans blamed oil companies for pushing up the price of gas; 70 percent blamed foreign oil producers and 68 percent the volatile situation in the Middle East, according to the survey.

Ninety percent of Americans backed the development of alternative energy as the best way out of the energy quagmire.

Other suggestions were to negotiate lower prices with oil exporting nations -- backed by 84 percent of respondents -- or to allow more offshore oil drilling in the United States, an option favored by 81 percent.

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Senate Finance Committee Health Reform Summit

(full announcement)

Hearing Statement of Senator Max Baucus (D-Mont.)Regarding the Health Care Marketplace

via CHW Thought Blog

Consumer Reports Health

Consumer Reports Health Launches Cover America Tour
To Highlight the Problems Americans Have With Health Care Coverage

RV Road Tour Begins May 28 & Will Travel Across the U.S. This Summer

YONKERS, NY – Consumer Reports Health is hitting the road this summer on the Cover America Tour to listen to Americans talk about their experiences with our nation’s health care system. The tour was launched today from the New York headquarters of Consumers Union, the nonprofit publisher of Consumer Reports Health, and will travel across the country by RV over the next four months.

As the Cover America Tour travels from coast to coast, its crew will post videos of people talking about the challenges they’ve experienced with health coverage and will blog with updates about what they’re hearing at www.CoverAmericaTour.org. The web site enables users to submit their own stories and to find out how they can join with thousands of others across the U.S. to support health care reform.

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Dying for Coverage

For the more than 47 million Americans who are uninsured, lack of health insurance can have dire consequences—medical debt, missed care, and even premature death. Click for the first-ever state reports on the number of deaths due to lack of health insurance. (March 2008)

2007 National Healthcare Quality & Disparities Reports

National Healthcare Quality Report and National Healthcare Disparities Report are available at the Agency for Healthcare Research and Quality website.

Click for State Snapshots

U.S. Healthcare Quality Measures Only Edging Up

The quality of healthcare improved nationwide at a rate of 2.3% per year from 1994 to 2005, revealed dozens of measures of effectiveness, timeliness, and patient safety and satisfaction reported by the government. But the pace of progress was slowing.

The average annual rate of improvement declined to just 1.5% from 2000 to 2005, reflecting the fact that not all states were moving in the right direction.

The best performing states across overall measures of healthcare -- Minnesota, Wisconsin, North Dakota, Iowa, and Nebraska -- all improved from the last analysis, according to the 2007 State Snapshots from the Agency for Healthcare Quality and Research.

Conversely, the five worst performers -- Louisiana, Georgia, Arkansas, Mississippi, and the District of Columbia -- all had declining scores.

Data for the snapshots were culled from the 2007 National Healthcare Quality Report.

"This year's State Snapshots do more than illustrate the wide variations in healthcare quality among states," said Carolyn Clancy, M.D., director of the agency. "They also show a handful of the important challenges that states face as they work to improve the quality of care."

The snapshots summarized healthcare quality for each state and the District of Columbia according to type of care (i.e., preventive, acute, or chronic), setting of care (i.e., nursing homes, hospitals, ambulatory, or home), and clinical area.

Rankings were provided for 15 of the most essential measures, covering quality of care for cancer, diabetes, end-stage renal disease, heart disease, and respiratory diseases, maternal and child health, mental health, nursing home and home healthcare, and patient experience.

Sitting at the top of one category did not necessarily mean that a state would be performing well in another category.

For example, Louisiana, which ranked last in overall healthcare quality, had the highest rate of breast cancer deaths, at 27.7 per 100,000 population per year, but beat all other states in the percentage of persons older than 65 who had ever received a pneumococcal vaccination (71.7%).

West Virginia had the highest rate of mortality from colorectal cancer at 22.2 per 100,000 population per year, but had the highest percentage of Medicare patients who said they always had good communication with physicians when receiving treatment (74.8%).

Utah had the lowest rate of colorectal cancer deaths at 12.4 per 100,000 population per year and the highest percentage of home healthcare patients (45.4%) who improved their ability to move around. On the other hand, the state had the lowest percentage of Medicare hemodialysis patients with a urea reduction ratio of 65% or higher (87.6%).

The District of Columbia, which ranked fifth from the bottom in overall healthcare, had the fewest suicide deaths per 100,000 population (5.7), but had the lowest percentage of persons over 65 who had ever received a pneumococcal vaccination (51.4%).

Here are the top- and bottom-ranked states for each of the 15 essential measures highlighted in the State Snapshots:

* Breast cancer deaths -- Best: Hawaii (15.7 per 100,000 population per year); Worst: Louisiana (27.7); all-state average 24.4.
* Colorectal cancer deaths -- Best: Utah (12.4 per 100,000 population per year); Worst: West Virginia (22.2); all-state average 17.8.
* Percentage of high-risk adults with diabetes who had received a flu shot in the past year -- Best: South Dakota (56%); Worst: Florida (25.2%); all-state average 36.3%.
* Percentage of Medicare hemodialysis patients with a urea reduction ratio of 65% or higher -- Best: Hawaii (96.9%); Worst: Utah (87.6%); all-state average 92.8%.
* Percentage of heart attack patients prescribed a beta-blocker at discharge -- Best: Massachusetts and South Dakota (97.8%); Worst: Nevada (90.5%); all-state average 95.3%.
* Percentage of heart attack patients with left ventricular systolic dysfunction prescribed an ACE inhibitor or an angiotensin receptor blocker at discharge -- Best: Colorado (91.4%); Worst: Vermont (71.7%); all-state average 83.9%.
* Percentage of women receiving prenatal care in their first trimester -- Best: Rhode Island and Vermont (90%); Worst: New Mexico (69.4%); all-state average 83.8%.
* Percentage of children receiving all recommended vaccinations -- Best: Massachusetts (93.5%); Worst: Nevada (66.7%); all-state average 81.8%.
* Suicide deaths -- Best: District of Columbia (5.7 per 100,000 population); Worst: Alaska (23.4); all-state average 10.4.
* Percentage of persons over 65 who had ever received a pneumococcal vaccination -- Best: Louisiana (71.7%); Worst: District of Columbia (51.4%); all-state average 66%.
* Percentage of long-stay nursing home residents who were physically restrained -- Best: Nebraska (1.3%); Worst: California (13.4%); all-state average 4.5%.
* Percentage of low-risk long-stay nursing home residents who have pressure sores -- Best: Mississippi (1.4%); Worst: Vermont (5.2%); all-state average 2.2%.
* Percentage of home healthcare patients who improved their ability to move around -- Best: Utah (45.4%); Worst: Minnesota (32.6%); all-state average 38.6%.
* Percentage of Medicare managed care patients who reported they always got an appointment for as soon as they wanted in the last 12 months -- Best: North Dakota (87.5%); Worst: New Mexico (60.7%); all-state average 74.7%.
* Percentage of Medicare managed care patients who said they always had good communication with physicians when receiving treatment -- Best: West Virginia (74.8%); Worst: Arizona (63.8%); all-state average 69.4%.

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France is healthcare leader, US comes dead last: study

France is tops, and the United States dead last, in providing timely and effective healthcare to its citizens, according to a survey Tuesday of preventable deaths in 19 industrialized countries.

The study by the Commonwealth Fund and published in the January/February issue of the journal Health Affairs measured developed countries' effectiveness at providing timely and effective healthcare.

The study, entitled "Measuring the Health of Nations: Updating an Earlier Analysis," was written by researchers from the London School of Hygiene and Tropical Medicine. It looked at death rates in subjects younger than 75 that could have been prevented by timely and effective medical care.

The researchers found that while most countries surveyed saw preventable deaths decline by an average of 16 percent, the United States saw only a four percent dip.

The non-profit Commonwealth Fund, which financed the study, expressed alarm at the findings.

"It is startling to see the US falling even farther behind on this crucial indicator of health system performance," said Commonwealth Fund Senior Vice President Cathy Schoen, who noted that "other countries are reducing these preventable deaths more rapidly, yet spending far less."

The 19 countries, in order of best to worst, were: France, Japan, Australia, Austria, Canada, Denmark, Finland, Germany, Greece, Ireland, Italy, Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, the United Kingdom and the United States.

Some countries showed dramatic improvement in the periods studied -- 1997 and 1998 and again between 2002 and 2003 -- outpacing the United States, which showed only slight improvement.

White the United States ranked 15th of 19 between 1997-98, by 2002-03 it had fallen to last place.

"It is notable that all countries have improved substantially except the US," said Ellen Nolte, lead author of the study.

Had the United States performed as well as any of the top three industrialized countries, there would have been 101,000 fewer deaths per year, the researchers said.