Wednesday, May 23, 2012

Trained Interpreters Seen As Necessary To Avoid Mishaps

Kaiser Health News reports: “Trained Interpreters For Patients With Limited English Can Help Avoid Medical Mishaps.”

Find the report (written by Michelle Andrews and posted May 21, 2012) here:

KHN reports that there are 25 million people in the United States with limited English proficiency, creating a heightened potential for medical mishaps due to miscommunications and understandings. (The Census Bureau estimates that nearly 9 percent of the population age 5 or older has limited English proficiency, defined as people who describe themselves as speaking English less than "very well.")

The point of the article: “A trained medical interpreter can make all the difference. Too often, however, interpreter services at hospitals and other medical settings are inadequate. Family members, including children, often step in, or the task falls to medical staff members who speak the required language with varying degrees of fluency.”

And the further point is that it is more than just experience. It’s the training. A study published in March in the online Annals of Emergency Medicine concludes that “such ad hoc interpreters make nearly twice as many potentially clinically significant interpreting errors as do trained interpreters.” Find the study here:

The study examined 57 interactions at two large pediatric emergency departments in Massachusetts. These encounters involved patients who spoke Spanish at home and had limited proficiency in English. Researchers analyzed audiotapes of the visits, looking for five types of errors, including word omissions, additions and substitutions as well as editorial comments and instances of false fluency (making up a term, such as calling an ear an "ear-o" instead of an "oreja")

They recorded 1,884 errors, of which 18 percent had potential clinical consequences.

For professionally trained interpreters with at least 100 hours of training, the proportion of errors with potential clinical significance was 2 percent. For professional interpreters with less training, the figure was 12 percent. Ad hoc interpreter errors were potentially clinically significant in nearly twice as many instances -- 22 percent. The figure was 20 percent for people with no interpreter at all.

The article goes on to discuss the legal obligations of hospitals under Title VI of the Civil Rights Act of 1964 – which prohibits discrimination based on race, color or national origin, and therefore, as applied by the courts, health care providers who accept federal funding (Medicare and Medicaid) must take steps to ensure that their services are accessible to people who are not fluent in English.

KHN reports that this puts hospitals and other medical providers in the a tough spot because the law prohibits them from asking patients to pay for translation services, but at the same time they may not receive adequate or in some cases any other reimbursement.

On this point: some states do reimburse providers for giving language services to enrollees in Medicaid and CHIP (the federal-state health program for children). There is some debate as to how many insurers provide access to interpreter services.

On the clinical side: Hospitals and other providers realize that providing competent interpreter services can help ensure that they don't miss or misdiagnose a condition that results in serious injury or death, say experts. Trained interpreters can also help providers save money by avoiding unnecessary tests and procedures. Some hospitals provide interpreter services around the clock through different modes of communication – face-to-face, telephone and video – delivered by a mix of trained staff interpreters and outside contractors. The report also notes that hospitals that understand the importance of interpreters will make it a budget item.

Medicare Advantage Star Rating System Questioned

Kaiser Health News reports on “Second Guessing Medicare’s Star Rating System.”

Find the article (by Marilyn Werber Serafini, KHN Staff Writer, May 20, 2012, and in collaboration with the Washington Post) at:

KHN reports that “as the federal government pumps billions of bonus dollars into private Medicare health plans to encourage better care, the quality rating system used to award the bonuses is coming under increasing fire.”

The report indicates that both the Government Accountability Office and the Medicare Payment Advisory Commission (MedPAC) question whether the $8 billion-plus program is mostly rewarding mediocre patient care. Find the GAO report at:  Find the MedPAC report at:

The star ratings are part of a push by the Obama administration to increase the quality of care provided by private plans that contract with Medicare. The ratings are based on 36 measures, ranging from rates of hospital readmissions to the volume of consumer complaints a plan gets. See this KNH article for background:

The administration had argued that Medicare Advantage plans cost more than traditional Medicare without providing better results for patients. The 2010 federal health law tried to remedy that discrepancy by cutting plan payments by $136 billion over ten years. But the star-rating bonus system is intended to restore some of that money to high-performing plans.

Supporters say the program is a part of a broad initiative to boost the quality of patient care and point to demonstrable improvements – for instance, a San Diego physicians’ group that discovered 700 Medicare patients with diabetes who were not getting annual eye exams, even though failure to get early treatment can result in blindness. (The article provides more detail here and gives a pro and con on the data analysis providers, large versus small, may be able to undertake to achieve such results.)

The program was actually created in 2007 as a guide to help seniors compare the quality of private health plans in the Medicare Advantage program. One quarter of older and disabled people now opt out of the traditional, government-run Medicare program in favor of private, mostly managed care plans. These often have lower premiums and extra benefits, such as coverage of hearing aids and eye glasses.

But the ratings had mostly been ignored by health plans and their enrollees. KHN reports that “only about a third of Medicare beneficiaries knew about the star ratings, and only half of that group considered the scores when choosing a health plan, according to a survey that Harris Interactive conducted last September for insurer Kaiser Permanente.”

The 2010 healthcare law changed that by attaching financial rewards to the program’s ratings. But the first round of ratings last fall showed that most plans have a long way to go. Only 12 earned a perfect score of five, on a scale of one to five, and about 9 percent were below average. The majority received scores of three, or three and a half stars – enough to earn the bonus money.
Going forward, here’s what to expect: After 2014, plans will need four or five stars to get bonuses. And if they have fewer than three stars, they won't be allowed to enroll beneficiaries through Medicare's website, and risk being booted from Medicare altogether. Already, five-star plans don't have to wait until open season to enroll new customers. Poor performers are branded with an icon on Medicare's website.

And here is the bottom line: The KHN article reports that “for some health plans, the bonus money accounts for as much as 7 percent of revenues, which can translate into a couple of billion dollars for a large health plan in a large state. Compensation of senior managers in Medicare Advantage has now been oriented around achieving star ratings.”

The money is particularly attractive to Medicare Advantage plans as the health law gradually reduces payment rates to bring them in line with what the government spends on beneficiaries in the traditional government-run program. This year, they will lose $6 billion in federal payments, and the bonus money is estimated to offset that reduction by about half.

The GAO and MedPAC are questioning the strategy of rewarding plans with average ratings. Bonuses are now going to plans that cover 93 percent of enrollees “at a time when Medicare already faces serious problems with cost control and long-term financing,” according to a March MedPAC report.

KHN quotes onathan Blum, deputy administrator for Medicare: “the incentives were made available to average-rated plans to spur rapid improvements. The higher the plan rates, the larger the payment it can get and that is turned back to providing a more generous package of benefits."

Thursday, May 17, 2012

Websites Provide Consumers Information on Hospitals

The Los Angeles Times reports: "Using data from government agencies and private watchdogs, several websites provide consumer information on hospitals."

By Scott J. Wilson, Los Angeles Times (May 13, 2012)

Find the article at:,0,1327979.story.

The LA Times reports that "Using data from government agencies and private watchdogs, several websites provide consumer information on hospitals."

The article lists the following sites: ( enables you to compare selected hospitals on dozens of measures, including infection prevention, intensive care mortality rate and overall patient experience. The site, run by the California HealthCare Foundation, offers the option of searching by hospital name, location or medical condition.

Hospital Compare ( from the U.S. Department of Health and Human Services looks at facilities nationwide. You can compare up to three hospitals side by side or compare a hospital's track record with state and national averages. You also can narrow your search to facilities offering particular surgical procedures.

The Leapfrog Group (, an employer coalition that promotes hospital safety and quality, annually surveys hospitals on safety, quality and cost measures. Participation is voluntary, so not all hospitals are included.

Quality Check (, a site operated by the accrediting organization known as the Joint Commission, offers ratings of hospitals as well as nursing homes, home care providers and laboratories.

The Medicare site has a feature ( that can help compare kidney dialysis centers in your area. For each facility, the site details the services offered and provides data on effectiveness and patient survival.

New HHS Tool Tracks Health System Performance Online

HHS has launced a new Web-based tool to bring together data sets from across the federal government in one place so Americans can monitor and measure how the nation’s health care system is performing.  The new site was announced by Health and Human Services Secretary Kathleen Sebelius on Tuesday (May 15).

Known as the Health System Measurement Project, it is intended to allow policy makers, health care providers and the public to develop consistent data-driven views of changes in critical U.S. health system indicators, HHS officials said.  The public can view data by age, income level, ethnicity, and other factors.

According to HHS: Using the Measurement Project, one can quickly view data on a given topical area from multiple sources, compare trends across measures and compare national trends with those at the state and regional level. For example, an individual could use the Measurement Project to monitor the percentage of people who have a specific source of ongoing medical care or track avoidable hospitalizations for adults and children by region or ethnic group.

“Ensuring all Americans have access to these data is an important way to make our health care system more open and transparent.” Sebelius said in a written statement.

Find Secretary Sebelius's entire statement at:

The project includes data from topical areas, such as access to care, cost and affordability, prevention and health information technology. It presents these indicators by population characteristics, such as age, sex, income level, insurance coverage, and geography.

The tool contains information on how the measures were calculated and provides users with direct links back to the original data sources, HHS officials said.

To access the Health System Measurement Project, go to

Wednesday, May 9, 2012

Non-Profit Hospitals Deal with Financial Stress

Kaiser Health News reports on a Columbus, Ohio patient “Sued Over an $1800 Hospital Bill”.

Find this article at Kaiser Health News:

Here is a story of a working family, “living paycheck to paycheck” and a debt collector for a local non-profit hospital demanding a minimum payment of $400 instead of the $20 the patient Lori Duff said she could afford to pay at the time.

KHN reports that “Duff was likely eligible for free care under the Mount Carmel Health System’s financial assistance policy, which offers medical care at no charge for patients earning less than 200 percent of the federal poverty level. But the debt collector kept calling and soon informed her that the hospital was planning to sue her for the money.”

Duff was one of nearly 1,600 people Mount Carmel sued in county court between 2009 and 2011. Most of them were patients like Duff who did not pay their medical bills. And apparently Duff was doing the right thing. When she became pregnant, she went straight to the local hospital to make sure mother and child were healthy and safe. “She assumed the care would be provided for free, either through an emergency Medicaid option offered to pregnant women or through the hospital’s financial assistance policy. But then, a few months after Henry was born, she started getting the letters and phone calls from the debt collector.”

Often, patients who have filled out financial assistance applications while at the hospital, assume their bills will be covered, and do not learn they owe money until collection agents begin calling.

So here’s the point of the article: Nonprofit hospitals, which pay no federal, state or local taxes (“giving them a competitive edge over their for-profit counterparts”) are “expected” to offer a free and discounted care for low-income patients. But even as more and more Americans need extra help after losing their jobs and health insurance in the recession, studies suggest that on average, nonprofits provide only slightly more free and reduced-cost care than for-profit hospitals.

Patient advocates argue the line dividing nonprofit hospitals and for-profit hospitals, which do not receive the tax exemption, has blurred.

The hospital in question doesn’t dispute its efforts to collect payments after services rendered. The health system's mission is to provide care to everyone, regardless of their ability to pay, explains the VP for patient financial services: "In order to provide charity in the community—and we provide a lot and do a lot of good – we have to collect payment from those who can afford to pay us."

The tax code requires nonprofits to provide a "community benefit" to maintain their federal tax exemption. An important part of that benefit is free and reduced cost care for the poor, though the requirement is not specific about how much is expected. The article cites a 2006 study by the Congressional Budget Office found that on average, nonprofits provide only slightly more uncompensated care than for-profit hospitals. On the other hand, the article also cites a separate study by the Internal Revenue Service of more than 500 nonprofit hospitals. That study suggests non-profits do more than their share: it found that 9 percent of hospitals provided 60 percent of all charity care.

Provisions in the 2010 health care law crafted by Sen. Chuck Grassley, R-Iowa and Sen. Max Baucus, D-Mont require non-profit hospitals to publicize their financial assistance policies and prohibits them from charging higher rates to uninsured patients or taking extreme collections efforts against patients who may qualify for free care.

Specifically, new rules that went into effect last year under the new health care law:

1) Prohibit non-profit hospitals from charging uninsured low-income patients higher rates that the lowest amounts billed to individuals with insurance

2) Require non-profits to have clearly written financial assistance policy describing who is eligible for free or reduced cost care (The policy must be widely publicized in the community served by the hospital.)

3) Prohibit non-profits from enforcing “extraordinary collections actions” against patients before determining whether the patient qualifies for financial assistance

4) Require non-profits to conduct assessments of the health needs of the community they serve and implement a strategy to meet those needs

The American Hospital Association says that non-profit hospitals support more transparency on these policies. The KHN reports that “the AHA estimates that nonprofit hospitals spend an average of 11 percent of their total expenses on benefits to their communities, though the calculation also includes bad debt, which they have tried and failed to collect, and shortfalls from the rates paid by Medicaid and Medicare, which hospitals say do not cover their costs.”

Given this, it’s worth considering a recent Moody’s report on the non-profit sector as well.

Reuters reports: “Nonprofit US hospitals to do more with less.” Find the article here:

Here is the problem: “Nonprofit hospitals in the United States face a future of rising costs and dwindling funds as the healthcare reform is implemented and the Congress battles over the budget”.

Here is the solution: “To survive what the rating agency is calling a "transition period," the hospitals, which frequently provide free or discounted care for lower-income patients, will have to drastically cut spending.”

And the source of the problem, according to Moody’s: “At the heart of the matter lies Medicare, the health insurance program for seniors which currently serves 49 million beneficiaries. Last month, an annual federal report on the Medicare fund found it is headed for exhaustion in 2024. Costs for the $549 billion-a-year program will likely leap from about 3.7 percent of gross domestic product in 2011 to 5.7 percent by 2035. Moody's said some of the health reform law's changes to how Medicare pays for procedures will stress nonprofit hospitals' finances. The law, which the Supreme Court could overturn in coming months, has lowered annual increases to Medicare payment rates.”

The article is written by Jenny Gold of Kaiser Health News. Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a non-profit, non-partisan health policy research and communication organization not affiliated with Kaiser Permanente. The story was produced in collaboration with NPR, National Public Radio.

Thursday, May 3, 2012

Observation status can trigger significant hospital fees for drugs

USA TODAY reports on “Patients held for observation can face steep drug bills”.

Find the article at USA TODAY Money

The article features a diabetic patient in the hospital for sudden chest pains whose charge for insulin during her 18-hour would have been enough to cover her out-of-pocket expenses for a three-month supply under her private Medicare Advantage plan.

Even though her health plan covers medical and drug expenses, her policy would not pay the hospital drug bill because the hospital never formally admitted her; instead, it billed the visit as observation care, which is considered outpatient service.
The “observation label” reportedly excludes thousands of patients every year from full Medicare coverage. Many have spent more than a day in the hospital and had regular hospital rooms and service and never realized they weren't admitted. These “observation patients” face paying a larger share of their hospital bills than inpatients, since they usually have a co-payment for doctors' fees and each hospital service.

The problem in many of these instances is that Medicare does not pay for routine drugs that observation patients need for chronic conditions such as diabetes, high blood pressure or high cholesterol — drugs that they could have brought from home if the hospital allowed it and the patient had time to get them. Apparently Medicare has no rules for what hospitals can bill for non-covered drugs, so they can charge any amount. The article reports that Medicare officials recommend to hospitals — but do not require — that patients remain under observation for no more than 24 to 48 hours. After that, the patients should be switched to inpatient status or discharged, the officials recommend. But patients can linger in observation for several days and often don't know they haven't been admitted.

Medicare does not limit the prices for drugs that it does not cover, hospitals use their pharmacies to help generate revenue to subsidize the other operating costs of the facility, said Miriam Mobley Smith, dean of the College of Pharmacy at Chicago State University. She said the "upcharge" is based on numerous factors, including personnel, insurance and facility costs. And the article states that even patients with private Medicare Part D drug insurance may find that their policies don't cover their everyday — or "self-administered" — drugs given to them in the hospital: "These drugs may be covered under certain circumstances," according to the Medicare website. But there is no requirement that Part D beneficiaries must be fully reimbursed for these drugs.

USA TODAY reports that the most recent government statistics show the number of observation claims that hospitals submitted to Medicare rose 46% to 1.4 million from 2006 to 2010, and the number of cases lasting longer than 48 hours more than tripled. The article also states that the American Hospital Association, in a 2010 letter to Medicare officials, cited several factors to explain that growth, including increasingly restrictive Medicare criteria for the hospital admission and rising use of audits to monitor hospital decisions and billing. In addition, it said, physicians sometimes try to keep seniors in the hospital because they may not be well enough to be home, even when they're not sick enough to be admitted.

There is a class-action lawsuit, filed by the Center for Medicare Advocacy, based in Connecticut, against the federal government on behalf of “observation patients” – who, because of their observation status, become ineligible for Medicare coverage for nursing home care when they leave the hospital. The lawsuit seeks to either eliminate the “observation status” or require hospitals to tell patients when they are admitted for observation and allow them to appeal the designation.

The article is written by Susan Jaffe of Kaiser Health News. Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a non-profit, non-partisan health policy research and communication organization not affiliated with Kaiser Permanente.

Congressional interest emerges in Accretive Health story

We blogged last week about the report on practices uncovered by the Minnesota Attorney General – results of the Minnesota attorney general's inquiry, released last week in a six-volume report that suggests Accretive Health violated federal laws while under contract with a Minneapolis hospital.

See New York Times article “Debt Collector Is Faulted for Tough Tactics in Hospitals” by Jessica Silver-Greenberg (April 24, 2012) at

This week reports “Lawmakers request client list from Accretive,” by Melanie Evans (posted May 2, 2012 - 1:45 pm ET).

Find this article here:

Now, Members of Congress are in the fray.

The findings raise questions about how common such practices may be, said Reps. Henry Waxman, (D-Calif.), Diana DeGette, (D-Colo.), and G.K. Butterfield, (D-N.C.), in a letter to Accretive CEO Mary Tolan (PDF). These Members of the U.S. House asked Accretive Health's CEO for a list of clients and information on the company's policies on compliance with federal emergency room access, patient privacy and debt collection laws. The request comes ahead of a scheduled May 4 congressional briefing by Accretive Health.

Accretive Health has rejected the attorney general's report and said findings “grossly distort and mischaracterize” its services. In an April 29 statement, reports that “the company said that more than 90% of the revenue Accretive Health collects comes from third-party payers.” “The suggestion that our focus or practice is to put bedside pressure on patients to pay their medical bills out of pocket is a flagrant distortion of fact,” the statement said.

Find its April 29 statement here or here:

The congressional letter requests that Accretive Health provide by May 14 a list of clients as well as information on guidance related to patient registration and collection efforts prior to treatment; policies and procedures related to EMTALA (Emergency Medical Treatment and Active Labor Act), federal private and debt collection laws; information on complaints and how the company estimates prices and patient bills; policies about refunds and information about whether its practices are standard across the industry.

The company faces interest on other fronts. Rep. Pete Stark (D-Calif.) last week called for HHS and the CMS to investigate Accretive Health.

See a follow-up New York Times article “In Congress, a Move to Look Into a Medical Debt Collector” by JESSICA SILVER-GREENBERG (April 26). Find this article here:

Rep. Pete Stark, a Democrat and highest ranking member of the subcommittee that oversees Medicare and other health services, on April 26, asked Marilyn B. Tavenner, the acting administrator for the Medicare and Medicaid agency, to investigate the company’s practices. He sent an identical letter to the inspector general of the Department of Health and Human Services, Daniel R. Levinson.

Specifically, Stark has urged officials at the CMS and HHS' inspector general's office to examine possible violations of federal law by Accretive. The California Democrat also asked that he be informed of enforcement measures and that Medicare-participating hospitals be notified immediately if any violations are found.

Find his letter here:

Links to the New York Times article may also be found here: