Mary Ellen Schneider

The Joint Commission's new 2008 patient safety goal of requiring a process to respond quickly to a deteriorating inpatient is being mistakenly interpreted at some hospitals as a mandate for “rapid response teams” or “medical emergency teams.”

Further, at some organizations that already have rapid response teams, staff have expressed concerns they will need to redo their established systems.

Dr. Peter Angood, vice president and chief patient safety officer for the Joint Commission, said such presumptions are incorrect.

Hospitals are simply being asked to select a “suitable method” that allows staff members to directly request assistance from a specially trained individual or individuals when a patient's condition appears to be worsening, he said. The key is to focus on early recognition of a deteriorating patient and mobilization of resources and to document the success or failure of the system that is in place.

“This is not a goal that states there needs to be a rapid response team,” Dr. Angood said.

Many institutions in the United States have implemented rapid response teams, and the data on their efficiency is generally good, but not every study has been positive, Dr. Angood said. As a result, officials at the Joint Commission wanted to move forward with a more basic approach with the goal of avoiding variation in response from day to day and from shift to shift.

Regardless of how hospitals choose to implement the Joint Commission goal, hospitalists are likely to play a significant role in accomplishing it, said Dr. Franklin Michota, director of academic affairs for the department of hospital medicine at the Cleveland Clinic.

Organizations that already have a hospitalist program are leaning toward the use of rapid response teams or medical emergency teams, because hospitalists can function as members of the team. Some hospitals without an adequate number of staff to have a team in place around the clock are considering starting hospitalist programs. Another strategy would be to form teams that do not include physicians, he said.

The Joint Commission requirement will not be without cost, Dr. Michota said, especially for those organizations that need to add staff. If no professional staff was there at 2 a.m. before, the hospital now needs to take on the cost of salary and benefits for more employees, he said.

When hospitalists aren't a part of a response team, they are likely to be central to developing the response plan, said Dr. Robert Wachter, chief of the division of hospital medicine at the University of California, San Francisco.

While the Joint Commission requirement might seem like a greater challenge for small hospitals, Brock Slabach, senior vice president for member services at the National Rural Health Association, disagrees. In many cases, smaller organizations can meet the Joint Commission's requirements in easier fashion than large, urban facilities can, because they are more nimble and can work faster with less bureaucracy.

Rapid response teams, for example, can be tailored to a hospital's resources by using staff from the emergency department to respond to a call, he said.

A number of hospitals have already made a commitment to establishing some type of rapid response teams. Establishing these teams is one of the strategies advocated as part of the Institute for Healthcare Improvement's 5 Million Lives Campaign, a national patient safety campaign.

Of the 3,800 hospitals enrolled in the 5 Million Lives Campaign as of January, about 2,700 have committed to using rapid response teams, according to IHI.

This idea is catching on, said Kathy Duncan, R.N., faculty for the 5 Million Lives Campaign.

The cost of implementing these types of teams varies, she said. About 75% of hospitals in the campaign have done this with zero increase in full-time employees, she said. For most staff involved, this is just an additional task. Investment is required for training team members, which can be costly at the outset, she said. Hospitals also need to invest time to educate the rest of the staff on when and how to call for assistance.

Ms. Duncan's advice for implementing whatever process hospitals choose to respond to the Joint Commission goal is to start by assessing what resources are available. Next, don't just jump into implementation, but take the time to test the process and figure out how people will request assistance, when to make that call, and who should respond.

“Start small with a pilot process,” Ms. Duncan said.

Implementing a Response Plan

Because of the complexity of implementing a process to respond quickly to a deteriorating patient, officials at the Joint Commission are giving hospitals a year to develop and phase in their program.

By April 1, the first deadline, hospital leaders were required to assign responsibility for the oversight, coordination, and development of the goals and requirements. By July 1, there needs to be an implementation work plan in place that identifies the resources needed. By Oct. 1, pilot testing in one clinical area should be underway.

The Joint Commission is serious about organizations meeting these implementation milestones, Dr. Angood said. Hospitals that don't meet the quarterly deadlines will be docked points on their evaluation.

For 2009, hospitals will need to comply with the following six “implementation expectations” set out by the Joint Commission:

▸ Select an early recognition and response method suitable to the hospital's needs and resources.

▸ Develop criteria for how and when to request assistance to respond to a change in a patient's condition.

▸ Empower staff, patients, and/or families to request additional assistance if they have a concern.

▸ Provide formal education about response policies and practices for both those who might respond and those who might request assistance.

▸ Measure the utility and effectiveness of the interventions.

▸ Measure cardiopulmonary arrest rates, respiratory arrest rates, and mortality rates before and after implementation of the program.

The Joint Commission's new 2008 patient safety goal of requiring a process to respond quickly to a deteriorating inpatient is being mistakenly interpreted at some hospitals as a mandate for “rapid response teams” or “medical emergency teams.”

Further, at some organizations that already have rapid response teams, staff have expressed concerns they will need to redo their established systems.

Dr. Peter Angood, vice president and chief patient safety officer for the Joint Commission, said such presumptions are incorrect.

Hospitals are simply being asked to select a “suitable method” that allows staff members to directly request assistance from a specially trained individual or individuals when a patient's condition appears to be worsening, he said. The key is to focus on early recognition of a deteriorating patient and mobilization of resources and to document the success or failure of the system that is in place.

“This is not a goal that states there needs to be a rapid response team,” Dr. Angood said.

Many institutions in the United States have implemented rapid response teams, and the data on their efficiency is generally good, but not every study has been positive, Dr. Angood said. As a result, officials at the Joint Commission wanted to move forward with a more basic approach with the goal of avoiding variation in response from day to day and from shift to shift.

Regardless of how hospitals choose to implement the Joint Commission goal, hospitalists are likely to play a significant role in accomplishing it, said Dr. Franklin Michota, director of academic affairs for the department of hospital medicine at the Cleveland Clinic.

Organizations that already have a hospitalist program are leaning toward the use of rapid response teams or medical emergency teams, because hospitalists can function as members of the team. Some hospitals without an adequate number of staff to have a team in place around the clock are considering starting hospitalist programs. Another strategy would be to form teams that do not include physicians, he said.

The Joint Commission requirement will not be without cost, Dr. Michota said, especially for those organizations that need to add staff. If no professional staff was there at 2 a.m. before, the hospital now needs to take on the cost of salary and benefits for more employees, he said.

When hospitalists aren't a part of a response team, they are likely to be central to developing the response plan, said Dr. Robert Wachter, chief of the division of hospital medicine at the University of California, San Francisco.

While the Joint Commission requirement might seem like a greater challenge for small hospitals, Brock Slabach, senior vice president for member services at the National Rural Health Association, disagrees. In many cases, smaller organizations can meet the Joint Commission's requirements in easier fashion than large, urban facilities can, because they are more nimble and can work faster with less bureaucracy.

Rapid response teams, for example, can be tailored to a hospital's resources by using staff from the emergency department to respond to a call, he said.

A number of hospitals have already made a commitment to establishing some type of rapid response teams. Establishing these teams is one of the strategies advocated as part of the Institute for Healthcare Improvement's 5 Million Lives Campaign, a national patient safety campaign.

Of the 3,800 hospitals enrolled in the 5 Million Lives Campaign as of January, about 2,700 have committed to using rapid response teams, according to IHI.

This idea is catching on, said Kathy Duncan, R.N., faculty for the 5 Million Lives Campaign.

The cost of implementing these types of teams varies, she said. About 75% of hospitals in the campaign have done this with zero increase in full-time employees, she said. For most staff involved, this is just an additional task. Investment is required for training team members, which can be costly at the outset, she said. Hospitals also need to invest time to educate the rest of the staff on when and how to call for assistance.

Ms. Duncan's advice for implementing whatever process hospitals choose to respond to the Joint Commission goal is to start by assessing what resources are available. Next, don't just jump into implementation, but take the time to test the process and figure out how people will request assistance, when to make that call, and who should respond.

“Start small with a pilot process,” Ms. Duncan said.

Implementing a Response Plan

Because of the complexity of implementing a process to respond quickly to a deteriorating patient, officials at the Joint Commission are giving hospitals a year to develop and phase in their program.

By April 1, the first deadline, hospital leaders were required to assign responsibility for the oversight, coordination, and development of the goals and requirements. By July 1, there needs to be an implementation work plan in place that identifies the resources needed. By Oct. 1, pilot testing in one clinical area should be underway.

The Joint Commission is serious about organizations meeting these implementation milestones, Dr. Angood said. Hospitals that don't meet the quarterly deadlines will be docked points on their evaluation.

For 2009, hospitals will need to comply with the following six “implementation expectations” set out by the Joint Commission:

▸ Select an early recognition and response method suitable to the hospital's needs and resources.

▸ Develop criteria for how and when to request assistance to respond to a change in a patient's condition.

▸ Empower staff, patients, and/or families to request additional assistance if they have a concern.

▸ Provide formal education about response policies and practices for both those who might respond and those who might request assistance.

▸ Measure the utility and effectiveness of the interventions.

▸ Measure cardiopulmonary arrest rates, respiratory arrest rates, and mortality rates before and after implementation of the program.

The Joint Commission's new 2008 patient safety goal of requiring a process to respond quickly to a deteriorating inpatient is being mistakenly interpreted at some hospitals as a mandate for “rapid response teams” or “medical emergency teams.”

Further, at some organizations that already have rapid response teams, staff have expressed concerns they will need to redo their established systems.

Dr. Peter Angood, vice president and chief patient safety officer for the Joint Commission, said such presumptions are incorrect.

Hospitals are simply being asked to select a “suitable method” that allows staff members to directly request assistance from a specially trained individual or individuals when a patient's condition appears to be worsening, he said. The key is to focus on early recognition of a deteriorating patient and mobilization of resources and to document the success or failure of the system that is in place.

“This is not a goal that states there needs to be a rapid response team,” Dr. Angood said.

Many institutions in the United States have implemented rapid response teams, and the data on their efficiency is generally good, but not every study has been positive, Dr. Angood said. As a result, officials at the Joint Commission wanted to move forward with a more basic approach with the goal of avoiding variation in response from day to day and from shift to shift.

Regardless of how hospitals choose to implement the Joint Commission goal, hospitalists are likely to play a significant role in accomplishing it, said Dr. Franklin Michota, director of academic affairs for the department of hospital medicine at the Cleveland Clinic.

Organizations that already have a hospitalist program are leaning toward the use of rapid response teams or medical emergency teams, because hospitalists can function as members of the team. Some hospitals without an adequate number of staff to have a team in place around the clock are considering starting hospitalist programs. Another strategy would be to form teams that do not include physicians, he said.

The Joint Commission requirement will not be without cost, Dr. Michota said, especially for those organizations that need to add staff. If no professional staff was there at 2 a.m. before, the hospital now needs to take on the cost of salary and benefits for more employees, he said.

When hospitalists aren't a part of a response team, they are likely to be central to developing the response plan, said Dr. Robert Wachter, chief of the division of hospital medicine at the University of California, San Francisco.

While the Joint Commission requirement might seem like a greater challenge for small hospitals, Brock Slabach, senior vice president for member services at the National Rural Health Association, disagrees. In many cases, smaller organizations can meet the Joint Commission's requirements in easier fashion than large, urban facilities can, because they are more nimble and can work faster with less bureaucracy.

Rapid response teams, for example, can be tailored to a hospital's resources by using staff from the emergency department to respond to a call, he said.

A number of hospitals have already made a commitment to establishing some type of rapid response teams. Establishing these teams is one of the strategies advocated as part of the Institute for Healthcare Improvement's 5 Million Lives Campaign, a national patient safety campaign.

Of the 3,800 hospitals enrolled in the 5 Million Lives Campaign as of January, about 2,700 have committed to using rapid response teams, according to IHI.

This idea is catching on, said Kathy Duncan, R.N., faculty for the 5 Million Lives Campaign.

The cost of implementing these types of teams varies, she said. About 75% of hospitals in the campaign have done this with zero increase in full-time employees, she said. For most staff involved, this is just an additional task. Investment is required for training team members, which can be costly at the outset, she said. Hospitals also need to invest time to educate the rest of the staff on when and how to call for assistance.

Ms. Duncan's advice for implementing whatever process hospitals choose to respond to the Joint Commission goal is to start by assessing what resources are available. Next, don't just jump into implementation, but take the time to test the process and figure out how people will request assistance, when to make that call, and who should respond.

“Start small with a pilot process,” Ms. Duncan said.

Implementing a Response Plan

Because of the complexity of implementing a process to respond quickly to a deteriorating patient, officials at the Joint Commission are giving hospitals a year to develop and phase in their program.

By April 1, the first deadline, hospital leaders were required to assign responsibility for the oversight, coordination, and development of the goals and requirements. By July 1, there needs to be an implementation work plan in place that identifies the resources needed. By Oct. 1, pilot testing in one clinical area should be underway.

The Joint Commission is serious about organizations meeting these implementation milestones, Dr. Angood said. Hospitals that don't meet the quarterly deadlines will be docked points on their evaluation.

For 2009, hospitals will need to comply with the following six “implementation expectations” set out by the Joint Commission:

▸ Select an early recognition and response method suitable to the hospital's needs and resources.

▸ Develop criteria for how and when to request assistance to respond to a change in a patient's condition.

▸ Empower staff, patients, and/or families to request additional assistance if they have a concern.

▸ Provide formal education about response policies and practices for both those who might respond and those who might request assistance.

▸ Measure the utility and effectiveness of the interventions.

▸ Measure cardiopulmonary arrest rates, respiratory arrest rates, and mortality rates before and after implementation of the program.

Rheums to Be Hit Hard by Fee Cuts

With only a couple of months left before a Medicare physician fee cut of more than 10% is scheduled to go into effect, the American Academy of Rheumatology is warning that such a cut could be devastating to rheumatologists and their patients. The projected cut, which will go into effect on July 1 if Congress does not act, is based on the sustainable growth rate formula (SGR) that links physician payments to the gross domestic product. The formula is flawed, the American Academy of Rheumatology said, not only because medical costs rarely fall in line with GDP, but because the sustainable growth rate formula also includes other costs that physicians have no control over, such as the cost of drugs. “The outcome is inevitable—without fundamental change, rheumatologists will be forced to start closing their doors to patients on Medicare, and these patients will be without care,” Dr. David A. Fox, ACR president, said in a statement. At press time, Congress was considering proposals to avert the scheduled cut. For example, one bill (S. 2785) would replace 18 months of cuts under Medicare with payment updates.

Falls Injure 5% of Those Over 65

Nearly 5% of individuals aged 65 years and older sustained an injury from a fall during a 3-month period, according to the Centers for Disease Control and Prevention. About 5.8 million Americans aged 65 and older reported falling at least once during a 3-month period, and for 1.8 million individuals, the fall was significant enough to either require a visit to the doctor or restrict activity for at least a day. The estimates, which were published in the March 7 issue of the Morbidity and Mortality Weekly Report, are based on data from the 2006 Behavioral Risk Factor Surveillance System. Reports of falls were similar among men (15%) and women (16%), but women had significantly more fall-related injuries, (36%), compared with men (25%). “Even when those injuries are minor, they can seriously affect older adults' quality of life by inducing a fear of falling, which can lead to self-imposed activity restrictions, social isolation, and depression,” the researchers at the CDC wrote.

Merck Makes Headway on Claims

About 47,000 individuals have registered eligible injuries as a result of taking the drug Vioxx, and more than 44,000 of those individuals have already submitted some or all of the materials that are needed to qualify for an interim payment, according to Merck & Co. The registration is part of a process to resolve state and federal product liability claims of myocardial infarction and ischemic stroke filed against Vioxx. Under the agreement, which was reached last November, Merck must pay $4.85 billion into the resolution fund in installments. Merck does not admit either causation or fault as a part of the settlement agreement. In order to qualify for payment, claimants must produce medical proof that they incurred a myocardial infarction or ischemic stroke, document receipt of at least 30 Vioxx pills, and have ingested the Vioxx pills within 14 days before the claimed injury. Those who meet the eligibility requirements will have their claims evaluated by the claims administrator. Merck plans to continue to fight all of the claims that are not part of the resolution program, according to a statement from the company.

CMS Finds Improper Payments

More than $371 million in improper Medicare payments was collected from or repaid to health care providers and suppliers in 2007 as part of a demonstration program that used recovery audit contractors in California, Florida, and New York, the Centers for Medicare and Medicaid Services announced. Almost all the improper payments (96%) that were identified in 2007 were overpayments collected from providers, while the remaining 4% were underpayments that were repaid to providers. Most of the improper payments occurred when health care providers submitted claims that did not comply with Medicare's coverage or coding rules, and more than 85% of the overpayments collected and almost all underpayments refunded were from claims submitted by inpatient hospitals. The demonstration program began in 2005 and was expanded to include Massachusetts, South Carolina, and Arizona in 2007.

Woodcock Named CDER Head

Dr. Janet Woodcock has been named director of the FDA's Center for Drug Evaluation and Research. Dr. Woodcock, a rheumatologist, served as director of CDER once before, in the 1990s, and has served as acting director since October 2007. The drug industry's chief lobbying group, PhRMA, welcomed the appointment. Dr. Woodcock “has demonstrated willingness to work with diverse partners, including researchers, Congress, the White House, patients, and pharmaceutical research companies,” said a statement from the group. However, there was dissent from Public Citizen's health research group director Dr. Sidney Wolfe, who commented in an interview that he's “not terribly hopeful” that Dr. Woodcock will lead the center well, because she doesn't like conflict or controversy. “I don't think she's the kind of CDER director we need right now,” Dr. Wolfe said. “She's aware of a number of drugs on the market that should be taken off the market, but I don't think she has the fortitude to do something about it.” CDER is charged with assuring that safe and effective drugs—including prescription, over-the-counter, and generic products—are available to Americans.

Rheums to Be Hit Hard by Fee Cuts

With only a couple of months left before a Medicare physician fee cut of more than 10% is scheduled to go into effect, the American Academy of Rheumatology is warning that such a cut could be devastating to rheumatologists and their patients. The projected cut, which will go into effect on July 1 if Congress does not act, is based on the sustainable growth rate formula (SGR) that links physician payments to the gross domestic product. The formula is flawed, the American Academy of Rheumatology said, not only because medical costs rarely fall in line with GDP, but because the sustainable growth rate formula also includes other costs that physicians have no control over, such as the cost of drugs. “The outcome is inevitable—without fundamental change, rheumatologists will be forced to start closing their doors to patients on Medicare, and these patients will be without care,” Dr. David A. Fox, ACR president, said in a statement. At press time, Congress was considering proposals to avert the scheduled cut. For example, one bill (S. 2785) would replace 18 months of cuts under Medicare with payment updates.

Falls Injure 5% of Those Over 65

Nearly 5% of individuals aged 65 years and older sustained an injury from a fall during a 3-month period, according to the Centers for Disease Control and Prevention. About 5.8 million Americans aged 65 and older reported falling at least once during a 3-month period, and for 1.8 million individuals, the fall was significant enough to either require a visit to the doctor or restrict activity for at least a day. The estimates, which were published in the March 7 issue of the Morbidity and Mortality Weekly Report, are based on data from the 2006 Behavioral Risk Factor Surveillance System. Reports of falls were similar among men (15%) and women (16%), but women had significantly more fall-related injuries, (36%), compared with men (25%). “Even when those injuries are minor, they can seriously affect older adults' quality of life by inducing a fear of falling, which can lead to self-imposed activity restrictions, social isolation, and depression,” the researchers at the CDC wrote.

Merck Makes Headway on Claims

About 47,000 individuals have registered eligible injuries as a result of taking the drug Vioxx, and more than 44,000 of those individuals have already submitted some or all of the materials that are needed to qualify for an interim payment, according to Merck & Co. The registration is part of a process to resolve state and federal product liability claims of myocardial infarction and ischemic stroke filed against Vioxx. Under the agreement, which was reached last November, Merck must pay $4.85 billion into the resolution fund in installments. Merck does not admit either causation or fault as a part of the settlement agreement. In order to qualify for payment, claimants must produce medical proof that they incurred a myocardial infarction or ischemic stroke, document receipt of at least 30 Vioxx pills, and have ingested the Vioxx pills within 14 days before the claimed injury. Those who meet the eligibility requirements will have their claims evaluated by the claims administrator. Merck plans to continue to fight all of the claims that are not part of the resolution program, according to a statement from the company.

CMS Finds Improper Payments

More than $371 million in improper Medicare payments was collected from or repaid to health care providers and suppliers in 2007 as part of a demonstration program that used recovery audit contractors in California, Florida, and New York, the Centers for Medicare and Medicaid Services announced. Almost all the improper payments (96%) that were identified in 2007 were overpayments collected from providers, while the remaining 4% were underpayments that were repaid to providers. Most of the improper payments occurred when health care providers submitted claims that did not comply with Medicare's coverage or coding rules, and more than 85% of the overpayments collected and almost all underpayments refunded were from claims submitted by inpatient hospitals. The demonstration program began in 2005 and was expanded to include Massachusetts, South Carolina, and Arizona in 2007.

Woodcock Named CDER Head

Dr. Janet Woodcock has been named director of the FDA's Center for Drug Evaluation and Research. Dr. Woodcock, a rheumatologist, served as director of CDER once before, in the 1990s, and has served as acting director since October 2007. The drug industry's chief lobbying group, PhRMA, welcomed the appointment. Dr. Woodcock “has demonstrated willingness to work with diverse partners, including researchers, Congress, the White House, patients, and pharmaceutical research companies,” said a statement from the group. However, there was dissent from Public Citizen's health research group director Dr. Sidney Wolfe, who commented in an interview that he's “not terribly hopeful” that Dr. Woodcock will lead the center well, because she doesn't like conflict or controversy. “I don't think she's the kind of CDER director we need right now,” Dr. Wolfe said. “She's aware of a number of drugs on the market that should be taken off the market, but I don't think she has the fortitude to do something about it.” CDER is charged with assuring that safe and effective drugs—including prescription, over-the-counter, and generic products—are available to Americans.

Rheums to Be Hit Hard by Fee Cuts

With only a couple of months left before a Medicare physician fee cut of more than 10% is scheduled to go into effect, the American Academy of Rheumatology is warning that such a cut could be devastating to rheumatologists and their patients. The projected cut, which will go into effect on July 1 if Congress does not act, is based on the sustainable growth rate formula (SGR) that links physician payments to the gross domestic product. The formula is flawed, the American Academy of Rheumatology said, not only because medical costs rarely fall in line with GDP, but because the sustainable growth rate formula also includes other costs that physicians have no control over, such as the cost of drugs. “The outcome is inevitable—without fundamental change, rheumatologists will be forced to start closing their doors to patients on Medicare, and these patients will be without care,” Dr. David A. Fox, ACR president, said in a statement. At press time, Congress was considering proposals to avert the scheduled cut. For example, one bill (S. 2785) would replace 18 months of cuts under Medicare with payment updates.

Falls Injure 5% of Those Over 65

Nearly 5% of individuals aged 65 years and older sustained an injury from a fall during a 3-month period, according to the Centers for Disease Control and Prevention. About 5.8 million Americans aged 65 and older reported falling at least once during a 3-month period, and for 1.8 million individuals, the fall was significant enough to either require a visit to the doctor or restrict activity for at least a day. The estimates, which were published in the March 7 issue of the Morbidity and Mortality Weekly Report, are based on data from the 2006 Behavioral Risk Factor Surveillance System. Reports of falls were similar among men (15%) and women (16%), but women had significantly more fall-related injuries, (36%), compared with men (25%). “Even when those injuries are minor, they can seriously affect older adults' quality of life by inducing a fear of falling, which can lead to self-imposed activity restrictions, social isolation, and depression,” the researchers at the CDC wrote.

Merck Makes Headway on Claims

About 47,000 individuals have registered eligible injuries as a result of taking the drug Vioxx, and more than 44,000 of those individuals have already submitted some or all of the materials that are needed to qualify for an interim payment, according to Merck & Co. The registration is part of a process to resolve state and federal product liability claims of myocardial infarction and ischemic stroke filed against Vioxx. Under the agreement, which was reached last November, Merck must pay $4.85 billion into the resolution fund in installments. Merck does not admit either causation or fault as a part of the settlement agreement. In order to qualify for payment, claimants must produce medical proof that they incurred a myocardial infarction or ischemic stroke, document receipt of at least 30 Vioxx pills, and have ingested the Vioxx pills within 14 days before the claimed injury. Those who meet the eligibility requirements will have their claims evaluated by the claims administrator. Merck plans to continue to fight all of the claims that are not part of the resolution program, according to a statement from the company.

CMS Finds Improper Payments

More than $371 million in improper Medicare payments was collected from or repaid to health care providers and suppliers in 2007 as part of a demonstration program that used recovery audit contractors in California, Florida, and New York, the Centers for Medicare and Medicaid Services announced. Almost all the improper payments (96%) that were identified in 2007 were overpayments collected from providers, while the remaining 4% were underpayments that were repaid to providers. Most of the improper payments occurred when health care providers submitted claims that did not comply with Medicare's coverage or coding rules, and more than 85% of the overpayments collected and almost all underpayments refunded were from claims submitted by inpatient hospitals. The demonstration program began in 2005 and was expanded to include Massachusetts, South Carolina, and Arizona in 2007.

Woodcock Named CDER Head

Dr. Janet Woodcock has been named director of the FDA's Center for Drug Evaluation and Research. Dr. Woodcock, a rheumatologist, served as director of CDER once before, in the 1990s, and has served as acting director since October 2007. The drug industry's chief lobbying group, PhRMA, welcomed the appointment. Dr. Woodcock “has demonstrated willingness to work with diverse partners, including researchers, Congress, the White House, patients, and pharmaceutical research companies,” said a statement from the group. However, there was dissent from Public Citizen's health research group director Dr. Sidney Wolfe, who commented in an interview that he's “not terribly hopeful” that Dr. Woodcock will lead the center well, because she doesn't like conflict or controversy. “I don't think she's the kind of CDER director we need right now,” Dr. Wolfe said. “She's aware of a number of drugs on the market that should be taken off the market, but I don't think she has the fortitude to do something about it.” CDER is charged with assuring that safe and effective drugs—including prescription, over-the-counter, and generic products—are available to Americans.

Health care spending in the United States is projected to consume nearly 20% of the gross domestic product by 2017, according to estimates from economists at the Centers for Medicare and Medicaid Services.

Health care spending growth is expected to remain steady at about 6.7% a year through 2017, with spending estimated to nearly double to $4.3 trillion by 2017, the CMS analysts said in a report published online in the journal Health Affairs.

The 10-year projections come from the National Health Statistics Group, part of the CMS Office of the Actuary, and are based on historical trends, projected economic conditions, and provisions of current law.

The analysts project that spending for private sector health care will slow toward the end of the projection period, while spending in the public sector, including Medicare and Medicaid, will increase. Much of the increase will be fueled by the first wave of baby boomers entering Medicare in 2011.

The increase in the number of Medicare enrollees is projected to add 2.9% to growth in Medicare spending by 2017, according to the report.

The CMS economists projected that growth in spending on physician services would average about 5.9% per year through 2017, compared with 6.6% from 1995 to 2006.

These projections are based on current law, which calls for steep cuts to physician payments under Medicare over the next several years.

If Congress were to provide a 0% update to Medicare payments over the next decade, the average annual growth from 2007 to 2017 would rise to 6.2%, according to the report.

On the hospital side, growth in spending is projected to accelerate at the beginning of the projection period because of higher Medicaid payments but to slow toward the end as a result of projected lower growth in income.

Home health care will likely be one of the fastest growing sectors in health care from 2007 through 2017, with an average annual spending growth rate of 7.7%, according to the report.

Additionally, growth in prescription drug spending is expected to accelerate overall through 2017, because of increased utilization, new drugs entering the market, and a leveling-off of the growth in generics.

The analysts reported that Medicare Part D would have “little impact on overall health spending growth” through the year 2017.

Health care spending in the United States is projected to consume nearly 20% of the gross domestic product by 2017, according to estimates from economists at the Centers for Medicare and Medicaid Services.

Health care spending growth is expected to remain steady at about 6.7% a year through 2017, with spending estimated to nearly double to $4.3 trillion by 2017, the CMS analysts said in a report published online in the journal Health Affairs.

The 10-year projections come from the National Health Statistics Group, part of the CMS Office of the Actuary, and are based on historical trends, projected economic conditions, and provisions of current law.

The analysts project that spending for private sector health care will slow toward the end of the projection period, while spending in the public sector, including Medicare and Medicaid, will increase. Much of the increase will be fueled by the first wave of baby boomers entering Medicare in 2011.

The increase in the number of Medicare enrollees is projected to add 2.9% to growth in Medicare spending by 2017, according to the report.

The CMS economists projected that growth in spending on physician services would average about 5.9% per year through 2017, compared with 6.6% from 1995 to 2006.

These projections are based on current law, which calls for steep cuts to physician payments under Medicare over the next several years.

If Congress were to provide a 0% update to Medicare payments over the next decade, the average annual growth from 2007 to 2017 would rise to 6.2%, according to the report.

On the hospital side, growth in spending is projected to accelerate at the beginning of the projection period because of higher Medicaid payments but to slow toward the end as a result of projected lower growth in income.

Home health care will likely be one of the fastest growing sectors in health care from 2007 through 2017, with an average annual spending growth rate of 7.7%, according to the report.

Additionally, growth in prescription drug spending is expected to accelerate overall through 2017, because of increased utilization, new drugs entering the market, and a leveling-off of the growth in generics.

The analysts reported that Medicare Part D would have “little impact on overall health spending growth” through the year 2017.

Health care spending in the United States is projected to consume nearly 20% of the gross domestic product by 2017, according to estimates from economists at the Centers for Medicare and Medicaid Services.

Health care spending growth is expected to remain steady at about 6.7% a year through 2017, with spending estimated to nearly double to $4.3 trillion by 2017, the CMS analysts said in a report published online in the journal Health Affairs.

The 10-year projections come from the National Health Statistics Group, part of the CMS Office of the Actuary, and are based on historical trends, projected economic conditions, and provisions of current law.

The analysts project that spending for private sector health care will slow toward the end of the projection period, while spending in the public sector, including Medicare and Medicaid, will increase. Much of the increase will be fueled by the first wave of baby boomers entering Medicare in 2011.

The increase in the number of Medicare enrollees is projected to add 2.9% to growth in Medicare spending by 2017, according to the report.

The CMS economists projected that growth in spending on physician services would average about 5.9% per year through 2017, compared with 6.6% from 1995 to 2006.

These projections are based on current law, which calls for steep cuts to physician payments under Medicare over the next several years.

If Congress were to provide a 0% update to Medicare payments over the next decade, the average annual growth from 2007 to 2017 would rise to 6.2%, according to the report.

On the hospital side, growth in spending is projected to accelerate at the beginning of the projection period because of higher Medicaid payments but to slow toward the end as a result of projected lower growth in income.

Home health care will likely be one of the fastest growing sectors in health care from 2007 through 2017, with an average annual spending growth rate of 7.7%, according to the report.

Additionally, growth in prescription drug spending is expected to accelerate overall through 2017, because of increased utilization, new drugs entering the market, and a leveling-off of the growth in generics.

The analysts reported that Medicare Part D would have “little impact on overall health spending growth” through the year 2017.

Most Americans favor an employer-based health insurance system, according to the results of a survey conducted by the Commonwealth Fund.

More than two-thirds of Americans who took part would favor a mandate for individuals to obtain health insurance in an effort to provide universal coverage.

The Democratic candidates would require employers to offer coverage to employees or pay for part of their coverage. The Republicans are proposing tax code changes to reduce employers' role in health insurance, according to a Commonwealth Fund analysis.

Sen. Hillary Clinton (D-N.Y.) supports an individual insurance mandate, while Sen. Barack Obama (D-Ill.) would mandate coverage for all children. Republican presidential nominee presumptive Sen. John McCain (R-Ariz.) does not propose an individual insurance mandate, according to the Commonwealth Fund.

From June to October 2007, the Commonwealth Fund conducted a telephone survey of 3,501 adults aged 19 years and older. About 81% of respondents said employers should either provide health insurance or contribute to a fund to cover all Americans. Support for this was high regardless of political affiliation, race, gender, age, and income.

Overall, 68% of respondents strongly or somewhat favor a mandate that all individuals get health insurance; 25% strongly or somewhat opposed; 7% didn't know, or refused to answer. When asked who should pay for health insurance for all Americans, 66% favored a system in which costs would be shared by individuals, employers, and the government.

About 15% said it should be mostly government financed; 8% said it should be paid mostly by employers; 6% said individuals should pay; 5% said they didn't know, or refused to answer.

Most Americans favor an employer-based health insurance system, according to the results of a survey conducted by the Commonwealth Fund.

More than two-thirds of Americans who took part would favor a mandate for individuals to obtain health insurance in an effort to provide universal coverage.

The Democratic candidates would require employers to offer coverage to employees or pay for part of their coverage. The Republicans are proposing tax code changes to reduce employers' role in health insurance, according to a Commonwealth Fund analysis.

Sen. Hillary Clinton (D-N.Y.) supports an individual insurance mandate, while Sen. Barack Obama (D-Ill.) would mandate coverage for all children. Republican presidential nominee presumptive Sen. John McCain (R-Ariz.) does not propose an individual insurance mandate, according to the Commonwealth Fund.

From June to October 2007, the Commonwealth Fund conducted a telephone survey of 3,501 adults aged 19 years and older. About 81% of respondents said employers should either provide health insurance or contribute to a fund to cover all Americans. Support for this was high regardless of political affiliation, race, gender, age, and income.

Overall, 68% of respondents strongly or somewhat favor a mandate that all individuals get health insurance; 25% strongly or somewhat opposed; 7% didn't know, or refused to answer. When asked who should pay for health insurance for all Americans, 66% favored a system in which costs would be shared by individuals, employers, and the government.

About 15% said it should be mostly government financed; 8% said it should be paid mostly by employers; 6% said individuals should pay; 5% said they didn't know, or refused to answer.

Most Americans favor an employer-based health insurance system, according to the results of a survey conducted by the Commonwealth Fund.

More than two-thirds of Americans who took part would favor a mandate for individuals to obtain health insurance in an effort to provide universal coverage.

The Democratic candidates would require employers to offer coverage to employees or pay for part of their coverage. The Republicans are proposing tax code changes to reduce employers' role in health insurance, according to a Commonwealth Fund analysis.

Sen. Hillary Clinton (D-N.Y.) supports an individual insurance mandate, while Sen. Barack Obama (D-Ill.) would mandate coverage for all children. Republican presidential nominee presumptive Sen. John McCain (R-Ariz.) does not propose an individual insurance mandate, according to the Commonwealth Fund.

From June to October 2007, the Commonwealth Fund conducted a telephone survey of 3,501 adults aged 19 years and older. About 81% of respondents said employers should either provide health insurance or contribute to a fund to cover all Americans. Support for this was high regardless of political affiliation, race, gender, age, and income.

Overall, 68% of respondents strongly or somewhat favor a mandate that all individuals get health insurance; 25% strongly or somewhat opposed; 7% didn't know, or refused to answer. When asked who should pay for health insurance for all Americans, 66% favored a system in which costs would be shared by individuals, employers, and the government.

About 15% said it should be mostly government financed; 8% said it should be paid mostly by employers; 6% said individuals should pay; 5% said they didn't know, or refused to answer.

Over the next 3 years, more than 100 hospitals will collect quality data on mortality, appropriate care, efficiency, harm avoidance, and patient satisfaction with the aim of improving care and controlling costs.

The Quest: High Performing Hospitals project, which was launched by Premier Inc., a hospital performance improvement alliance, is also designed to test performance measures that will likely be included in future pay-for-performance programs.

“It's an opportunity to learn but also to guide the industry,” said Stephanie Alexander, senior vice president and general manager of Premier's informatics division.

In the short term, the program is aimed at preparing hospitals for a world of value-based purchasing and pay for performance. Over the long term, it should help hospitals improve quality and safety while safely reducing costs. “It's really a laboratory,” said Dr. Richard A. Bankowitz, vice president and medical director for the informatics division.

Premier began recruiting hospitals for the program last summer and in January started collecting quality data. Over the course of the project, Premier will collect data on the following:

▸ Mortality, by using a risk-adjusted ratio to measure progress toward the goal of eliminating all avoidable deaths.

▸ Evidence-based care, via a measure of the percentage of patients receiving “perfect care” based on nationally recognized quality measures.

▸ Efficiency, through a measure of total inpatient cost per case-mix-adjusted discharge, including all of the costs associated with each episode of acute care.

▸ Patient experience, as measured using the Centers for Medicare and Medicaid Services' Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction measures. The program will also study how patient satisfaction can relate to cost, quality, and safety.

▸ Harm avoidance, via measures of the prevention of health care-associated infections and adverse drug events. Premier is working with the Institute for Healthcare Improvement to develop automated measures of harm that can be reported without having to perform a manual chart review.

The first year of the program will focus on mortality, evidence-based care, and efficiency. The hospitals will take on harm avoidance and patient satisfaction during the second year.

Premier will analyze the data from each hospital, disseminate best practices among the facilities, and provide financial incentives to the top-performing hospitals at the end of the 3-year project. The amount of the reward pool has yet to be determined. However, there are no penalties for hospitals who don't meet the goals.

There was no cost for hospitals to participate, Ms. Alexander said, but they needed to have a commitment at both the executive and board levels to meeting the quality goals. They also had to commit to data collection and sharing best practice knowledge, she said. Premier also encouraged hospitals not to make Quest a “special” project but to incorporate it into the everyday business of the facility.

The project builds on the success of the Hospital Quality Incentive Demonstration project, a pay-for-performance initiative performed in collaboration with the Centers for Medicare and Medicaid Services that showed significant improvements in quality and reductions in the cost of care.

The Medicare demonstration showed that hospitals can improve both quality and cost and that there is no reason to think the lessons learned can't be applied beyond the conditions in the pilot project, said Dr. Stephen Schoenbaum, executive vice president for programs at the Commonwealth Fund and a member of the Quest advisory panel.

North Mississippi Health Services in Tupelo didn't participate in the Medicare demonstration project, but they matched its progress on their own; this time around they were the first to sign up for Quest.

It's obvious that both the government and private payers are moving forward with pay for performance, said Dr. Ken Davis, chief medical officer for North Mississippi Health Services. He and his colleagues want to ensure that when the payers move forward, the measures used are valid, fair, and clinically relevant.

Over the next 3 years, more than 100 hospitals will collect quality data on mortality, appropriate care, efficiency, harm avoidance, and patient satisfaction with the aim of improving care and controlling costs.

The Quest: High Performing Hospitals project, which was launched by Premier Inc., a hospital performance improvement alliance, is also designed to test performance measures that will likely be included in future pay-for-performance programs.

“It's an opportunity to learn but also to guide the industry,” said Stephanie Alexander, senior vice president and general manager of Premier's informatics division.

In the short term, the program is aimed at preparing hospitals for a world of value-based purchasing and pay for performance. Over the long term, it should help hospitals improve quality and safety while safely reducing costs. “It's really a laboratory,” said Dr. Richard A. Bankowitz, vice president and medical director for the informatics division.

Premier began recruiting hospitals for the program last summer and in January started collecting quality data. Over the course of the project, Premier will collect data on the following:

▸ Mortality, by using a risk-adjusted ratio to measure progress toward the goal of eliminating all avoidable deaths.

▸ Evidence-based care, via a measure of the percentage of patients receiving “perfect care” based on nationally recognized quality measures.

▸ Efficiency, through a measure of total inpatient cost per case-mix-adjusted discharge, including all of the costs associated with each episode of acute care.

▸ Patient experience, as measured using the Centers for Medicare and Medicaid Services' Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction measures. The program will also study how patient satisfaction can relate to cost, quality, and safety.

▸ Harm avoidance, via measures of the prevention of health care-associated infections and adverse drug events. Premier is working with the Institute for Healthcare Improvement to develop automated measures of harm that can be reported without having to perform a manual chart review.

The first year of the program will focus on mortality, evidence-based care, and efficiency. The hospitals will take on harm avoidance and patient satisfaction during the second year.

Premier will analyze the data from each hospital, disseminate best practices among the facilities, and provide financial incentives to the top-performing hospitals at the end of the 3-year project. The amount of the reward pool has yet to be determined. However, there are no penalties for hospitals who don't meet the goals.

There was no cost for hospitals to participate, Ms. Alexander said, but they needed to have a commitment at both the executive and board levels to meeting the quality goals. They also had to commit to data collection and sharing best practice knowledge, she said. Premier also encouraged hospitals not to make Quest a “special” project but to incorporate it into the everyday business of the facility.

The project builds on the success of the Hospital Quality Incentive Demonstration project, a pay-for-performance initiative performed in collaboration with the Centers for Medicare and Medicaid Services that showed significant improvements in quality and reductions in the cost of care.

The Medicare demonstration showed that hospitals can improve both quality and cost and that there is no reason to think the lessons learned can't be applied beyond the conditions in the pilot project, said Dr. Stephen Schoenbaum, executive vice president for programs at the Commonwealth Fund and a member of the Quest advisory panel.

North Mississippi Health Services in Tupelo didn't participate in the Medicare demonstration project, but they matched its progress on their own; this time around they were the first to sign up for Quest.

It's obvious that both the government and private payers are moving forward with pay for performance, said Dr. Ken Davis, chief medical officer for North Mississippi Health Services. He and his colleagues want to ensure that when the payers move forward, the measures used are valid, fair, and clinically relevant.

Over the next 3 years, more than 100 hospitals will collect quality data on mortality, appropriate care, efficiency, harm avoidance, and patient satisfaction with the aim of improving care and controlling costs.

The Quest: High Performing Hospitals project, which was launched by Premier Inc., a hospital performance improvement alliance, is also designed to test performance measures that will likely be included in future pay-for-performance programs.

“It's an opportunity to learn but also to guide the industry,” said Stephanie Alexander, senior vice president and general manager of Premier's informatics division.

In the short term, the program is aimed at preparing hospitals for a world of value-based purchasing and pay for performance. Over the long term, it should help hospitals improve quality and safety while safely reducing costs. “It's really a laboratory,” said Dr. Richard A. Bankowitz, vice president and medical director for the informatics division.

Premier began recruiting hospitals for the program last summer and in January started collecting quality data. Over the course of the project, Premier will collect data on the following:

▸ Mortality, by using a risk-adjusted ratio to measure progress toward the goal of eliminating all avoidable deaths.

▸ Evidence-based care, via a measure of the percentage of patients receiving “perfect care” based on nationally recognized quality measures.

▸ Efficiency, through a measure of total inpatient cost per case-mix-adjusted discharge, including all of the costs associated with each episode of acute care.

▸ Patient experience, as measured using the Centers for Medicare and Medicaid Services' Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction measures. The program will also study how patient satisfaction can relate to cost, quality, and safety.

▸ Harm avoidance, via measures of the prevention of health care-associated infections and adverse drug events. Premier is working with the Institute for Healthcare Improvement to develop automated measures of harm that can be reported without having to perform a manual chart review.

The first year of the program will focus on mortality, evidence-based care, and efficiency. The hospitals will take on harm avoidance and patient satisfaction during the second year.

Premier will analyze the data from each hospital, disseminate best practices among the facilities, and provide financial incentives to the top-performing hospitals at the end of the 3-year project. The amount of the reward pool has yet to be determined. However, there are no penalties for hospitals who don't meet the goals.

There was no cost for hospitals to participate, Ms. Alexander said, but they needed to have a commitment at both the executive and board levels to meeting the quality goals. They also had to commit to data collection and sharing best practice knowledge, she said. Premier also encouraged hospitals not to make Quest a “special” project but to incorporate it into the everyday business of the facility.

The project builds on the success of the Hospital Quality Incentive Demonstration project, a pay-for-performance initiative performed in collaboration with the Centers for Medicare and Medicaid Services that showed significant improvements in quality and reductions in the cost of care.

The Medicare demonstration showed that hospitals can improve both quality and cost and that there is no reason to think the lessons learned can't be applied beyond the conditions in the pilot project, said Dr. Stephen Schoenbaum, executive vice president for programs at the Commonwealth Fund and a member of the Quest advisory panel.

North Mississippi Health Services in Tupelo didn't participate in the Medicare demonstration project, but they matched its progress on their own; this time around they were the first to sign up for Quest.

It's obvious that both the government and private payers are moving forward with pay for performance, said Dr. Ken Davis, chief medical officer for North Mississippi Health Services. He and his colleagues want to ensure that when the payers move forward, the measures used are valid, fair, and clinically relevant.

The Joint Commission on Accreditation of Healthcare Organizations' new 2008 patient safety goal of requiring a process to respond quickly to a deteriorating patient is being mistakenly interpreted at some hospitals as a mandate for rapid response teams or medical emergency teams, while other organizations that already have rapid response teams are concerned they will need to redo their established systems.

But Dr. Peter Angood, vice president and chief patient safety officer for the Joint Commission, said such presumptions are incorrect—hospitals are simply being asked to select a “suitable method” that allows staff to request assistance from a specially trained individual or team when a patient's condition seems to be worsening.

The key is to focus on early recognition of a deteriorating patient and the mobilization of resources and to document the success or failure of the system that is in place, he said. “This is not a goal that states there needs to be a rapid response team.”

Many institutions have implemented rapid response teams, and the data on their efficiency is generally good, but not every study has been positive, Dr. Angood said. As a result, officials at the Joint Commission wanted to move forward with a more basic approach to avoid variation in response from day to day and between shifts. (See box.)

Hospitalists are likely to play a significant role in accomplishing this goal, said Dr. Franklin Michota, director of academic affairs for the department of hospital medicine at the Cleveland Clinic.

Those with hospitalist programs in place are leaning toward using rapid response teams or medical emergency teams, because hospitalists can function as team members. Some hospitals that do not have enough staff to have a 24-hour team in place are considering starting hospitalist programs. Yet another strategy is to form teams that do not include physicians, he said.

But the requirement will not be without cost, Dr. Michota said, especially for organizations that have to add staff.

When hospitalists aren't a part of a response team, they are likely to be central to developing the response plan, said Dr. Robert Wachter, chief of the division of hospital medicine at the University of California, San Francisco. Perhaps the biggest role for the hospitalist is in providing the around-the-clock coverage that could negate the need to call the formal response team as often, he said.

Brock Slabach, senior vice president for member services at the National Rural Health Association, argued that smaller organizations might be able to meet the commission requirements more easily than large, urban facilities can, because they are more flexible and can work faster because there is less bureaucracy.

A number of hospitals have already made a commitment to establish some type of rapid response teams, which is one of the strategies advocated as part of the Institute for Healthcare Improvement's 5 Million Lives Campaign, a national patient safety campaign for reducing harm in hospitals.

Of the 3,800 hospitals enrolled in the 5 Million Lives Campaign as of January, about 2,700 have committed to using rapid response teams, according to the IHI.

The cost of implementing these types of teams varies, said Kathy Duncan, R.N., faculty for the 5 Million Lives Campaign. About 75% of hospitals in the campaign have done this without an increase in their full-time employees, because for most staff, it just entailed an additional task. But investment is required for training team members, which can be costly, she said.

Ms. Duncan said hospitals should start by assessing their available resources, then before implementation, they should test the process. “Start small with a pilot process,” she advised.

Implementing the Response Plan

Because of the complexity of implementing a process to respond quickly to a deteriorating patient, officials at the Joint Commission are giving hospitals a year to develop and phase in their program.

By April 1, the first deadline, hospital leaders were required to assign responsibility for the oversight, coordination, and development of the goals and requirements. By July 1, there needs to be an implementation work plan in place that identifies the resources needed. By Oct. 1, pilot testing in one clinical area should be underway.

The Joint Commission is serious about organizations meeting these implementation milestones, Dr. Angood said. Hospitals that don't meet the quarterly deadlines will be docked points on their evaluation.

For 2009, hospitals will need to comply with the following six “implementation expectations” set out by the Joint Commission:

▸ Select an early recognition and response method suitable to the hospital's needs and resources.

▸ Develop criteria for how and when to request additional assistance to respond to a change in a patient's condition.

▸ Empower staff, patients, and/or families to request additional assistance if they have a concern.

▸ Provide formal education about response policies and practices for both those who might respond and those who might request assistance.

▸ Measure the utility and effectiveness of the interventions.

▸ Measure cardiopulmonary arrest rates, respiratory arrest rates, and mortality rates before and after implementation of the program.

The Joint Commission on Accreditation of Healthcare Organizations' new 2008 patient safety goal of requiring a process to respond quickly to a deteriorating patient is being mistakenly interpreted at some hospitals as a mandate for rapid response teams or medical emergency teams, while other organizations that already have rapid response teams are concerned they will need to redo their established systems.

But Dr. Peter Angood, vice president and chief patient safety officer for the Joint Commission, said such presumptions are incorrect—hospitals are simply being asked to select a “suitable method” that allows staff to request assistance from a specially trained individual or team when a patient's condition seems to be worsening.

The key is to focus on early recognition of a deteriorating patient and the mobilization of resources and to document the success or failure of the system that is in place, he said. “This is not a goal that states there needs to be a rapid response team.”

Many institutions have implemented rapid response teams, and the data on their efficiency is generally good, but not every study has been positive, Dr. Angood said. As a result, officials at the Joint Commission wanted to move forward with a more basic approach to avoid variation in response from day to day and between shifts. (See box.)

Hospitalists are likely to play a significant role in accomplishing this goal, said Dr. Franklin Michota, director of academic affairs for the department of hospital medicine at the Cleveland Clinic.

Those with hospitalist programs in place are leaning toward using rapid response teams or medical emergency teams, because hospitalists can function as team members. Some hospitals that do not have enough staff to have a 24-hour team in place are considering starting hospitalist programs. Yet another strategy is to form teams that do not include physicians, he said.

But the requirement will not be without cost, Dr. Michota said, especially for organizations that have to add staff.

When hospitalists aren't a part of a response team, they are likely to be central to developing the response plan, said Dr. Robert Wachter, chief of the division of hospital medicine at the University of California, San Francisco. Perhaps the biggest role for the hospitalist is in providing the around-the-clock coverage that could negate the need to call the formal response team as often, he said.

Brock Slabach, senior vice president for member services at the National Rural Health Association, argued that smaller organizations might be able to meet the commission requirements more easily than large, urban facilities can, because they are more flexible and can work faster because there is less bureaucracy.

A number of hospitals have already made a commitment to establish some type of rapid response teams, which is one of the strategies advocated as part of the Institute for Healthcare Improvement's 5 Million Lives Campaign, a national patient safety campaign for reducing harm in hospitals.

Of the 3,800 hospitals enrolled in the 5 Million Lives Campaign as of January, about 2,700 have committed to using rapid response teams, according to the IHI.

The cost of implementing these types of teams varies, said Kathy Duncan, R.N., faculty for the 5 Million Lives Campaign. About 75% of hospitals in the campaign have done this without an increase in their full-time employees, because for most staff, it just entailed an additional task. But investment is required for training team members, which can be costly, she said.

Ms. Duncan said hospitals should start by assessing their available resources, then before implementation, they should test the process. “Start small with a pilot process,” she advised.

Implementing the Response Plan

Because of the complexity of implementing a process to respond quickly to a deteriorating patient, officials at the Joint Commission are giving hospitals a year to develop and phase in their program.

By April 1, the first deadline, hospital leaders were required to assign responsibility for the oversight, coordination, and development of the goals and requirements. By July 1, there needs to be an implementation work plan in place that identifies the resources needed. By Oct. 1, pilot testing in one clinical area should be underway.

The Joint Commission is serious about organizations meeting these implementation milestones, Dr. Angood said. Hospitals that don't meet the quarterly deadlines will be docked points on their evaluation.

For 2009, hospitals will need to comply with the following six “implementation expectations” set out by the Joint Commission:

▸ Select an early recognition and response method suitable to the hospital's needs and resources.

▸ Develop criteria for how and when to request additional assistance to respond to a change in a patient's condition.

▸ Empower staff, patients, and/or families to request additional assistance if they have a concern.

▸ Provide formal education about response policies and practices for both those who might respond and those who might request assistance.

▸ Measure the utility and effectiveness of the interventions.

▸ Measure cardiopulmonary arrest rates, respiratory arrest rates, and mortality rates before and after implementation of the program.

The Joint Commission on Accreditation of Healthcare Organizations' new 2008 patient safety goal of requiring a process to respond quickly to a deteriorating patient is being mistakenly interpreted at some hospitals as a mandate for rapid response teams or medical emergency teams, while other organizations that already have rapid response teams are concerned they will need to redo their established systems.

But Dr. Peter Angood, vice president and chief patient safety officer for the Joint Commission, said such presumptions are incorrect—hospitals are simply being asked to select a “suitable method” that allows staff to request assistance from a specially trained individual or team when a patient's condition seems to be worsening.

The key is to focus on early recognition of a deteriorating patient and the mobilization of resources and to document the success or failure of the system that is in place, he said. “This is not a goal that states there needs to be a rapid response team.”

Many institutions have implemented rapid response teams, and the data on their efficiency is generally good, but not every study has been positive, Dr. Angood said. As a result, officials at the Joint Commission wanted to move forward with a more basic approach to avoid variation in response from day to day and between shifts. (See box.)

Hospitalists are likely to play a significant role in accomplishing this goal, said Dr. Franklin Michota, director of academic affairs for the department of hospital medicine at the Cleveland Clinic.

Those with hospitalist programs in place are leaning toward using rapid response teams or medical emergency teams, because hospitalists can function as team members. Some hospitals that do not have enough staff to have a 24-hour team in place are considering starting hospitalist programs. Yet another strategy is to form teams that do not include physicians, he said.

But the requirement will not be without cost, Dr. Michota said, especially for organizations that have to add staff.

When hospitalists aren't a part of a response team, they are likely to be central to developing the response plan, said Dr. Robert Wachter, chief of the division of hospital medicine at the University of California, San Francisco. Perhaps the biggest role for the hospitalist is in providing the around-the-clock coverage that could negate the need to call the formal response team as often, he said.

Brock Slabach, senior vice president for member services at the National Rural Health Association, argued that smaller organizations might be able to meet the commission requirements more easily than large, urban facilities can, because they are more flexible and can work faster because there is less bureaucracy.

A number of hospitals have already made a commitment to establish some type of rapid response teams, which is one of the strategies advocated as part of the Institute for Healthcare Improvement's 5 Million Lives Campaign, a national patient safety campaign for reducing harm in hospitals.

Of the 3,800 hospitals enrolled in the 5 Million Lives Campaign as of January, about 2,700 have committed to using rapid response teams, according to the IHI.

The cost of implementing these types of teams varies, said Kathy Duncan, R.N., faculty for the 5 Million Lives Campaign. About 75% of hospitals in the campaign have done this without an increase in their full-time employees, because for most staff, it just entailed an additional task. But investment is required for training team members, which can be costly, she said.

Ms. Duncan said hospitals should start by assessing their available resources, then before implementation, they should test the process. “Start small with a pilot process,” she advised.

Implementing the Response Plan

Because of the complexity of implementing a process to respond quickly to a deteriorating patient, officials at the Joint Commission are giving hospitals a year to develop and phase in their program.

By April 1, the first deadline, hospital leaders were required to assign responsibility for the oversight, coordination, and development of the goals and requirements. By July 1, there needs to be an implementation work plan in place that identifies the resources needed. By Oct. 1, pilot testing in one clinical area should be underway.

The Joint Commission is serious about organizations meeting these implementation milestones, Dr. Angood said. Hospitals that don't meet the quarterly deadlines will be docked points on their evaluation.

For 2009, hospitals will need to comply with the following six “implementation expectations” set out by the Joint Commission:

▸ Select an early recognition and response method suitable to the hospital's needs and resources.

▸ Develop criteria for how and when to request additional assistance to respond to a change in a patient's condition.

▸ Empower staff, patients, and/or families to request additional assistance if they have a concern.

▸ Provide formal education about response policies and practices for both those who might respond and those who might request assistance.

▸ Measure the utility and effectiveness of the interventions.

▸ Measure cardiopulmonary arrest rates, respiratory arrest rates, and mortality rates before and after implementation of the program.

In response to a warning that the Medicare trust fund is in financial trouble, the Bush administration recently proposed legislation that would tie physician payments to quality, cap medical liability damages, and encourage nationwide adoption of electronic health records.

Health and Human Services Secretary Mike Leavitt submitted the proposed legislation to Congress last month, in response to the Medicare Trustees' warning for the second year in a row that general federal revenue would be needed to pay for more than 45% of program expenditures. Mr. Leavitt was required to submit the proposal under a cost-saving measure included in the Medicare Modernization Act of 2003.

“The Medicare program is on an unsustainable path, driven by two principal factors: projected growth in its per-capita costs, and increases in the beneficiary population as a result of population aging,” Mr. Leavitt said in a letter to House Speaker Nancy Pelosi (D-Calif.). “Excess cost growth will not be brought under control until there is comprehensive reform changing Medicare's underlying structure.”

Under the proposal, the HHS secretary would design and implement a system to tie a portion of the Medicare payment to providers to performance on quality and efficiency measures. Implementation would start in areas with well-accepted measures such as hospitals, physician offices, home health agencies, skilled nursing facilities, and renal dialysis facilities.

The legislation also would limit the length of time that individuals have to sue for medical malpractice, would cap noneconomic damages at $250,000 and punitive damages at $250,000 or twice the economic damages (whichever is greater), and would limit contingency fees paid to plaintiffs' attorneys. The HHS estimates that defensive medicine raises the cost of care in federal programs including Medicare, Medicaid, and Veterans Affairs, by about $28 billion a year.

Starting in 2009, the administration's proposal would also increase beneficiary premiums for Part D prescription drug coverage for single beneficiaries earning more than $82,000 a year and couples earning more than $164,000. The HHS estimates that the change would save more than $900 million in 2009 and nearly $3.2 billion over 5 years.

The legislative proposal also requires the HHS secretary to develop a system to encourage the nationwide adoption and use of interoperable electronic health records and to make personal health records available to Medicare beneficiaries.

Mr. Leavitt urged Congress to adopt the proposed changes in conjunction with the administration's fiscal year 2009 budget proposal, which includes legislative and administrative proposals that would cut $12.8 billion from the Medicare program in fiscal year 2009 and about $183 billion over the next 5 years.

But the administration may encounter some trouble getting its proposals through Congress.

Sen. Edward Kennedy (D-Mass.), chair of the Senate Health, Education, Labor, and Pensions Committee, said the administration's proposed Medicare cuts were dead on arrival. “The administration has trumped up a phony crisis in Medicare to justify proposing deep cuts in quality health care for seniors while giving massive subsidies to HMOs and other insurance companies,” he said in a statement.

Physicians' groups were also critical of the plan. Dr. James King, president of the American Academy of Family Physicians, said they were disappointed that the Medicare proposal failed to address the approximate 10% Medicare payment cut facing physicians this summer.

Dr. King also questioned the administration's proposal to move ahead with “value-based” payments to physicians under a plan that appears not to include additional money for incentives. Any pay-for-performance system should use a bonus payment, not withhold payments to some physicians, he said.

'Excess cost growth will not be brought under control until there is comprehensive reform.' MR. LEAVITT

In response to a warning that the Medicare trust fund is in financial trouble, the Bush administration recently proposed legislation that would tie physician payments to quality, cap medical liability damages, and encourage nationwide adoption of electronic health records.

Health and Human Services Secretary Mike Leavitt submitted the proposed legislation to Congress last month, in response to the Medicare Trustees' warning for the second year in a row that general federal revenue would be needed to pay for more than 45% of program expenditures. Mr. Leavitt was required to submit the proposal under a cost-saving measure included in the Medicare Modernization Act of 2003.

“The Medicare program is on an unsustainable path, driven by two principal factors: projected growth in its per-capita costs, and increases in the beneficiary population as a result of population aging,” Mr. Leavitt said in a letter to House Speaker Nancy Pelosi (D-Calif.). “Excess cost growth will not be brought under control until there is comprehensive reform changing Medicare's underlying structure.”

Under the proposal, the HHS secretary would design and implement a system to tie a portion of the Medicare payment to providers to performance on quality and efficiency measures. Implementation would start in areas with well-accepted measures such as hospitals, physician offices, home health agencies, skilled nursing facilities, and renal dialysis facilities.

The legislation also would limit the length of time that individuals have to sue for medical malpractice, would cap noneconomic damages at $250,000 and punitive damages at $250,000 or twice the economic damages (whichever is greater), and would limit contingency fees paid to plaintiffs' attorneys. The HHS estimates that defensive medicine raises the cost of care in federal programs including Medicare, Medicaid, and Veterans Affairs, by about $28 billion a year.

Starting in 2009, the administration's proposal would also increase beneficiary premiums for Part D prescription drug coverage for single beneficiaries earning more than $82,000 a year and couples earning more than $164,000. The HHS estimates that the change would save more than $900 million in 2009 and nearly $3.2 billion over 5 years.

The legislative proposal also requires the HHS secretary to develop a system to encourage the nationwide adoption and use of interoperable electronic health records and to make personal health records available to Medicare beneficiaries.

Mr. Leavitt urged Congress to adopt the proposed changes in conjunction with the administration's fiscal year 2009 budget proposal, which includes legislative and administrative proposals that would cut $12.8 billion from the Medicare program in fiscal year 2009 and about $183 billion over the next 5 years.

But the administration may encounter some trouble getting its proposals through Congress.

Sen. Edward Kennedy (D-Mass.), chair of the Senate Health, Education, Labor, and Pensions Committee, said the administration's proposed Medicare cuts were dead on arrival. “The administration has trumped up a phony crisis in Medicare to justify proposing deep cuts in quality health care for seniors while giving massive subsidies to HMOs and other insurance companies,” he said in a statement.

Physicians' groups were also critical of the plan. Dr. James King, president of the American Academy of Family Physicians, said they were disappointed that the Medicare proposal failed to address the approximate 10% Medicare payment cut facing physicians this summer.

Dr. King also questioned the administration's proposal to move ahead with “value-based” payments to physicians under a plan that appears not to include additional money for incentives. Any pay-for-performance system should use a bonus payment, not withhold payments to some physicians, he said.

'Excess cost growth will not be brought under control until there is comprehensive reform.' MR. LEAVITT

In response to a warning that the Medicare trust fund is in financial trouble, the Bush administration recently proposed legislation that would tie physician payments to quality, cap medical liability damages, and encourage nationwide adoption of electronic health records.

Health and Human Services Secretary Mike Leavitt submitted the proposed legislation to Congress last month, in response to the Medicare Trustees' warning for the second year in a row that general federal revenue would be needed to pay for more than 45% of program expenditures. Mr. Leavitt was required to submit the proposal under a cost-saving measure included in the Medicare Modernization Act of 2003.

“The Medicare program is on an unsustainable path, driven by two principal factors: projected growth in its per-capita costs, and increases in the beneficiary population as a result of population aging,” Mr. Leavitt said in a letter to House Speaker Nancy Pelosi (D-Calif.). “Excess cost growth will not be brought under control until there is comprehensive reform changing Medicare's underlying structure.”

Under the proposal, the HHS secretary would design and implement a system to tie a portion of the Medicare payment to providers to performance on quality and efficiency measures. Implementation would start in areas with well-accepted measures such as hospitals, physician offices, home health agencies, skilled nursing facilities, and renal dialysis facilities.

The legislation also would limit the length of time that individuals have to sue for medical malpractice, would cap noneconomic damages at $250,000 and punitive damages at $250,000 or twice the economic damages (whichever is greater), and would limit contingency fees paid to plaintiffs' attorneys. The HHS estimates that defensive medicine raises the cost of care in federal programs including Medicare, Medicaid, and Veterans Affairs, by about $28 billion a year.

Starting in 2009, the administration's proposal would also increase beneficiary premiums for Part D prescription drug coverage for single beneficiaries earning more than $82,000 a year and couples earning more than $164,000. The HHS estimates that the change would save more than $900 million in 2009 and nearly $3.2 billion over 5 years.

The legislative proposal also requires the HHS secretary to develop a system to encourage the nationwide adoption and use of interoperable electronic health records and to make personal health records available to Medicare beneficiaries.

Mr. Leavitt urged Congress to adopt the proposed changes in conjunction with the administration's fiscal year 2009 budget proposal, which includes legislative and administrative proposals that would cut $12.8 billion from the Medicare program in fiscal year 2009 and about $183 billion over the next 5 years.

But the administration may encounter some trouble getting its proposals through Congress.

Sen. Edward Kennedy (D-Mass.), chair of the Senate Health, Education, Labor, and Pensions Committee, said the administration's proposed Medicare cuts were dead on arrival. “The administration has trumped up a phony crisis in Medicare to justify proposing deep cuts in quality health care for seniors while giving massive subsidies to HMOs and other insurance companies,” he said in a statement.

Physicians' groups were also critical of the plan. Dr. James King, president of the American Academy of Family Physicians, said they were disappointed that the Medicare proposal failed to address the approximate 10% Medicare payment cut facing physicians this summer.

Dr. King also questioned the administration's proposal to move ahead with “value-based” payments to physicians under a plan that appears not to include additional money for incentives. Any pay-for-performance system should use a bonus payment, not withhold payments to some physicians, he said.

'Excess cost growth will not be brought under control until there is comprehensive reform.' MR. LEAVITT

Health care spending in the United States is projected to consume nearly 20% of the gross domestic product by 2017, according to estimates from economists at the Centers for Medicare and Medicaid Services.

Health care spending growth is expected to remain steady at about 6.7% a year through 2017, with spending estimated to nearly double to $4.3 trillion by 2017, the CMS analysts said in a report published online in the journal Health Affairs.

The 10-year projections come from the National Health Statistics Group, part of the CMS Office of the Actuary, and are based on historical trends, projected economic conditions, and provisions of current law.

The analysts project that spending for private sector health care will slow toward the end of the projection period, while spending in the public sector, including Medicare and Medicaid, will increase. Much of the increase will be fueled by the first wave of baby boomers entering Medicare in 2011. The increase in the number of Medicare enrollees is projected to add 2.9% to growth in Medicare spending by 2017, according to the report.

The CMS economists projected that growth in spending on physician services would average about 5.9% per year through 2017, compared with 6.6% from 1995 to 2006. These projections are based on current law, which calls for steep cuts to physician payments under Medicare over the next several years. If Congress were to provide a 0% update over the next decade, the average annual growth from 2007 to 2017 would rise to 6.2%, according to the report.

On the hospital side, growth in spending is projected to accelerate at the beginning of the projection period because of higher Medicaid payments but to slow toward the end as a result of projected lower growth in income.

Home health care will likely be one of the fastest growing sectors in health care from 2007 through 2017, with an average annual spending growth rate of 7.7%, according to the report.

Growth in prescription drug spending is expected to accelerate overall through 2017, because of increased utilization, new drugs entering the market, and a leveling-off of the growth in generics. The analysts reported that Medicare Part D would have “little impact on overall health spending growth” through 2017.

Health care spending in the United States is projected to consume nearly 20% of the gross domestic product by 2017, according to estimates from economists at the Centers for Medicare and Medicaid Services.

Health care spending growth is expected to remain steady at about 6.7% a year through 2017, with spending estimated to nearly double to $4.3 trillion by 2017, the CMS analysts said in a report published online in the journal Health Affairs.

The 10-year projections come from the National Health Statistics Group, part of the CMS Office of the Actuary, and are based on historical trends, projected economic conditions, and provisions of current law.

The analysts project that spending for private sector health care will slow toward the end of the projection period, while spending in the public sector, including Medicare and Medicaid, will increase. Much of the increase will be fueled by the first wave of baby boomers entering Medicare in 2011. The increase in the number of Medicare enrollees is projected to add 2.9% to growth in Medicare spending by 2017, according to the report.

The CMS economists projected that growth in spending on physician services would average about 5.9% per year through 2017, compared with 6.6% from 1995 to 2006. These projections are based on current law, which calls for steep cuts to physician payments under Medicare over the next several years. If Congress were to provide a 0% update over the next decade, the average annual growth from 2007 to 2017 would rise to 6.2%, according to the report.

On the hospital side, growth in spending is projected to accelerate at the beginning of the projection period because of higher Medicaid payments but to slow toward the end as a result of projected lower growth in income.

Home health care will likely be one of the fastest growing sectors in health care from 2007 through 2017, with an average annual spending growth rate of 7.7%, according to the report.

Growth in prescription drug spending is expected to accelerate overall through 2017, because of increased utilization, new drugs entering the market, and a leveling-off of the growth in generics. The analysts reported that Medicare Part D would have “little impact on overall health spending growth” through 2017.

Health care spending in the United States is projected to consume nearly 20% of the gross domestic product by 2017, according to estimates from economists at the Centers for Medicare and Medicaid Services.

Health care spending growth is expected to remain steady at about 6.7% a year through 2017, with spending estimated to nearly double to $4.3 trillion by 2017, the CMS analysts said in a report published online in the journal Health Affairs.

The 10-year projections come from the National Health Statistics Group, part of the CMS Office of the Actuary, and are based on historical trends, projected economic conditions, and provisions of current law.

The analysts project that spending for private sector health care will slow toward the end of the projection period, while spending in the public sector, including Medicare and Medicaid, will increase. Much of the increase will be fueled by the first wave of baby boomers entering Medicare in 2011. The increase in the number of Medicare enrollees is projected to add 2.9% to growth in Medicare spending by 2017, according to the report.

The CMS economists projected that growth in spending on physician services would average about 5.9% per year through 2017, compared with 6.6% from 1995 to 2006. These projections are based on current law, which calls for steep cuts to physician payments under Medicare over the next several years. If Congress were to provide a 0% update over the next decade, the average annual growth from 2007 to 2017 would rise to 6.2%, according to the report.

On the hospital side, growth in spending is projected to accelerate at the beginning of the projection period because of higher Medicaid payments but to slow toward the end as a result of projected lower growth in income.

Home health care will likely be one of the fastest growing sectors in health care from 2007 through 2017, with an average annual spending growth rate of 7.7%, according to the report.

Growth in prescription drug spending is expected to accelerate overall through 2017, because of increased utilization, new drugs entering the market, and a leveling-off of the growth in generics. The analysts reported that Medicare Part D would have “little impact on overall health spending growth” through 2017.

The physicians, nurses, and other clinical staffers at Tacoma (Wash.) General Hospital aren't sweating the new Joint Commission on Accreditation of Healthcare Organizations' requirements on central line-associated bloodstream infections that are scheduled to be phased in throughout 2009.

They have already implemented a central-line protocol that has brought their hospital's infection rate down to virtually zero over the last few years.

“Rather than accepting a certain rate of infections, we adopted the position that they should never happen,” said Dr. James R. Taylor, medical director of the adult intensive care unit at Tacoma General Hospital and the hospital's physician champion on reducing central-line infections.

In 2005, he began educating physicians and nurses in his ICU about a bundle of measures for reducing central-line infections that he learned about as part of the TICU (Transformation of the ICU) project, a program from the national health care alliance VHA Inc.

Before implementing the central-line protocol, Tacoma General Hospital had an infection rate of about 1.5–2.0 infections per 1,000 central-line days, which was better than the national benchmark set by the Centers for Disease Control and Prevention. Since 2005, the hospital's central line-associated infection rate has been even lower. There were no infections in the adult ICU at Tacoma General Hospital for all of 2006 and 2007, said Marcia Patrick, R.N., director of infection prevention and control for MultiCare Health System, which operates Tacoma General Hospital and three other hospitals in the area.

“It's a whole change in mind-set to zero tolerance,” Ms. Patrick said.

Based on the success in the ICU, the hospital generalized the process to the emergency department, operating rooms, and anywhere else central-line placement was being performed.

The protocol is surprisingly simple, Dr. Taylor said. The main elements are proper hand hygiene, the use of chlorhexidine-based antiseptic for skin preparation, the use of a sterile drape to cover the whole patient, the placement of the line in those locations shown to have lower infection rates, and the removal of the catheter as soon as possible.

The key is to make it easy to follow the measures and difficult to do things the wrong way, Dr. Taylor said. For example, the hospital decided to remove from its line carts anything that might contribute to improper line placement, and to include only those materials that would aid in proper line placement.

Another element of the hospital's success has been empowering the nurses to speak up, Dr. Taylor said. Under the protocol, if a physician breaks sterile technique during the line placement, the nurses are required to step in and ask the physician to stop and start over. The hospital also created a checklist for the nurses to record that all the proper steps in the line placement were performed.

“It's pretty simple stuff, but when you do it in every line placement, the infections go away,” Dr. Taylor said.

The physicians, nurses, and other clinical staffers at Tacoma (Wash.) General Hospital aren't sweating the new Joint Commission on Accreditation of Healthcare Organizations' requirements on central line-associated bloodstream infections that are scheduled to be phased in throughout 2009.

They have already implemented a central-line protocol that has brought their hospital's infection rate down to virtually zero over the last few years.

“Rather than accepting a certain rate of infections, we adopted the position that they should never happen,” said Dr. James R. Taylor, medical director of the adult intensive care unit at Tacoma General Hospital and the hospital's physician champion on reducing central-line infections.

In 2005, he began educating physicians and nurses in his ICU about a bundle of measures for reducing central-line infections that he learned about as part of the TICU (Transformation of the ICU) project, a program from the national health care alliance VHA Inc.

Before implementing the central-line protocol, Tacoma General Hospital had an infection rate of about 1.5–2.0 infections per 1,000 central-line days, which was better than the national benchmark set by the Centers for Disease Control and Prevention. Since 2005, the hospital's central line-associated infection rate has been even lower. There were no infections in the adult ICU at Tacoma General Hospital for all of 2006 and 2007, said Marcia Patrick, R.N., director of infection prevention and control for MultiCare Health System, which operates Tacoma General Hospital and three other hospitals in the area.

“It's a whole change in mind-set to zero tolerance,” Ms. Patrick said.

Based on the success in the ICU, the hospital generalized the process to the emergency department, operating rooms, and anywhere else central-line placement was being performed.

The protocol is surprisingly simple, Dr. Taylor said. The main elements are proper hand hygiene, the use of chlorhexidine-based antiseptic for skin preparation, the use of a sterile drape to cover the whole patient, the placement of the line in those locations shown to have lower infection rates, and the removal of the catheter as soon as possible.

The key is to make it easy to follow the measures and difficult to do things the wrong way, Dr. Taylor said. For example, the hospital decided to remove from its line carts anything that might contribute to improper line placement, and to include only those materials that would aid in proper line placement.

Another element of the hospital's success has been empowering the nurses to speak up, Dr. Taylor said. Under the protocol, if a physician breaks sterile technique during the line placement, the nurses are required to step in and ask the physician to stop and start over. The hospital also created a checklist for the nurses to record that all the proper steps in the line placement were performed.

“It's pretty simple stuff, but when you do it in every line placement, the infections go away,” Dr. Taylor said.

The physicians, nurses, and other clinical staffers at Tacoma (Wash.) General Hospital aren't sweating the new Joint Commission on Accreditation of Healthcare Organizations' requirements on central line-associated bloodstream infections that are scheduled to be phased in throughout 2009.

They have already implemented a central-line protocol that has brought their hospital's infection rate down to virtually zero over the last few years.

“Rather than accepting a certain rate of infections, we adopted the position that they should never happen,” said Dr. James R. Taylor, medical director of the adult intensive care unit at Tacoma General Hospital and the hospital's physician champion on reducing central-line infections.

In 2005, he began educating physicians and nurses in his ICU about a bundle of measures for reducing central-line infections that he learned about as part of the TICU (Transformation of the ICU) project, a program from the national health care alliance VHA Inc.

Before implementing the central-line protocol, Tacoma General Hospital had an infection rate of about 1.5–2.0 infections per 1,000 central-line days, which was better than the national benchmark set by the Centers for Disease Control and Prevention. Since 2005, the hospital's central line-associated infection rate has been even lower. There were no infections in the adult ICU at Tacoma General Hospital for all of 2006 and 2007, said Marcia Patrick, R.N., director of infection prevention and control for MultiCare Health System, which operates Tacoma General Hospital and three other hospitals in the area.

“It's a whole change in mind-set to zero tolerance,” Ms. Patrick said.

Based on the success in the ICU, the hospital generalized the process to the emergency department, operating rooms, and anywhere else central-line placement was being performed.

The protocol is surprisingly simple, Dr. Taylor said. The main elements are proper hand hygiene, the use of chlorhexidine-based antiseptic for skin preparation, the use of a sterile drape to cover the whole patient, the placement of the line in those locations shown to have lower infection rates, and the removal of the catheter as soon as possible.

The key is to make it easy to follow the measures and difficult to do things the wrong way, Dr. Taylor said. For example, the hospital decided to remove from its line carts anything that might contribute to improper line placement, and to include only those materials that would aid in proper line placement.

Another element of the hospital's success has been empowering the nurses to speak up, Dr. Taylor said. Under the protocol, if a physician breaks sterile technique during the line placement, the nurses are required to step in and ask the physician to stop and start over. The hospital also created a checklist for the nurses to record that all the proper steps in the line placement were performed.

“It's pretty simple stuff, but when you do it in every line placement, the infections go away,” Dr. Taylor said.

The full report is available online at www.mathematica-mpr.com/health/dirigochoice.asp

As more state policy makers consider their options for expanding health insurance coverage, the experience of Maine's Dirigo Health may offer a road map for avoiding potential missteps.

Under the Dirigo Health initiative, which began in 2005, the state offered subsidized health insurance for small businesses, self-employed workers, and low- and moderate-income individuals through a program called DirigoChoice. In addition, the state increased the annual income eligibility level for its Medicaid program, MaineCare, to include parents of children under age 19 years who were at or below 200% of the federal poverty level.

The goal behind the Dirigo Health initiative has been to provide access to affordable health coverage for every Maine resident by 2009. (“Dirigo,” part of Maine's motto, means “I direct” in Latin.)

Although the program has seen success in targeting subsidies to low-income individuals, it also has run into problems meeting its financial goals and hitting enrollment targets, according to a report commissioned by the Commonwealth Fund. The report evaluated the program as of September 2006.

“The implementation can be just as difficult as actually passing the law,” said Debra J. Lipson, the lead author of the report and a senior researcher at Mathematica Policy Research Inc., based in Washington.

When the Dirigo Health Reform Act was passed in 2003, the program was touted as a means to achieve universal access to health insurance and targeted the 136,000 uninsured Maine residents. The state estimated that in the first year of the program, it would enroll about 41,000 individuals.

But the program has fallen short of those expectations and, as of September 2006, had enrolled about 11,100 individuals in DirigoChoice. About 5,000 individuals were enrolled in the MaineCare expansion. An additional 18,100 individuals were covered through an earlier MaineCare expansion that targeted low-income childless adults.

The higher total enrollments in the two MaineCare expansions indicate that states can have success in increasing enrollment when they offer fully subsidized insurance options, the researchers concluded. But, as in the case in Maine, those expansions come with a large price tag.

Another problem for the Maine program is that DirigoChoice remains unaffordable for many small employers. About 700 small firms were enrolled in the program as of September 2006, comprising about 2.5% of all eligible small businesses. About 83% of firms that did not offer the program or any other health coverage said they failed to offer benefits because premiums were too high, according to the report.

Paying for the program also has been difficult in Maine. Most of the cost was supposed to be offset by savings from lower uncompensated care. But how savings are measured has been controversial from the start, and the program has not been able to generate enough revenue, the report said.

The savings offset payment formula even was challenged in court by insurers and the state's chamber of commerce. Although the Maine Supreme Court sided with the state in May 2007, the formula is widely viewed as “politically unsustainable in its current form,” according to the report.

The type of enrollment in the Dirigo Health program also has created funding problems for Maine. For example, enrollment by previously uninsured individuals has been lower than expected, leading to a lower reduction in charity care costs and limiting the revenues that could be raised for the program. As a result of this and other revenue shortfalls, the state has had to institute periodic enrollment freezes.

Creating affordable health insurance options was a challenge in Maine because there was little provider competition and a highly concentrated insurance market, the report noted.

In many ways the Maine experience is a cautionary tale for other states, said Tarren Bragdon, CEO of the Maine Heritage Policy Center in Portland. The program missed the mark by not limiting benefits to only the uninsured, he said, and states with limited resources should consider taking a more targeted approach.

The full report is available online at www.mathematica-mpr.com/health/dirigochoice.asp

As more state policy makers consider their options for expanding health insurance coverage, the experience of Maine's Dirigo Health may offer a road map for avoiding potential missteps.

Under the Dirigo Health initiative, which began in 2005, the state offered subsidized health insurance for small businesses, self-employed workers, and low- and moderate-income individuals through a program called DirigoChoice. In addition, the state increased the annual income eligibility level for its Medicaid program, MaineCare, to include parents of children under age 19 years who were at or below 200% of the federal poverty level.

The goal behind the Dirigo Health initiative has been to provide access to affordable health coverage for every Maine resident by 2009. (“Dirigo,” part of Maine's motto, means “I direct” in Latin.)

Although the program has seen success in targeting subsidies to low-income individuals, it also has run into problems meeting its financial goals and hitting enrollment targets, according to a report commissioned by the Commonwealth Fund. The report evaluated the program as of September 2006.

“The implementation can be just as difficult as actually passing the law,” said Debra J. Lipson, the lead author of the report and a senior researcher at Mathematica Policy Research Inc., based in Washington.

When the Dirigo Health Reform Act was passed in 2003, the program was touted as a means to achieve universal access to health insurance and targeted the 136,000 uninsured Maine residents. The state estimated that in the first year of the program, it would enroll about 41,000 individuals.

But the program has fallen short of those expectations and, as of September 2006, had enrolled about 11,100 individuals in DirigoChoice. About 5,000 individuals were enrolled in the MaineCare expansion. An additional 18,100 individuals were covered through an earlier MaineCare expansion that targeted low-income childless adults.

The higher total enrollments in the two MaineCare expansions indicate that states can have success in increasing enrollment when they offer fully subsidized insurance options, the researchers concluded. But, as in the case in Maine, those expansions come with a large price tag.

Another problem for the Maine program is that DirigoChoice remains unaffordable for many small employers. About 700 small firms were enrolled in the program as of September 2006, comprising about 2.5% of all eligible small businesses. About 83% of firms that did not offer the program or any other health coverage said they failed to offer benefits because premiums were too high, according to the report.

Paying for the program also has been difficult in Maine. Most of the cost was supposed to be offset by savings from lower uncompensated care. But how savings are measured has been controversial from the start, and the program has not been able to generate enough revenue, the report said.

The savings offset payment formula even was challenged in court by insurers and the state's chamber of commerce. Although the Maine Supreme Court sided with the state in May 2007, the formula is widely viewed as “politically unsustainable in its current form,” according to the report.

The type of enrollment in the Dirigo Health program also has created funding problems for Maine. For example, enrollment by previously uninsured individuals has been lower than expected, leading to a lower reduction in charity care costs and limiting the revenues that could be raised for the program. As a result of this and other revenue shortfalls, the state has had to institute periodic enrollment freezes.

Creating affordable health insurance options was a challenge in Maine because there was little provider competition and a highly concentrated insurance market, the report noted.

In many ways the Maine experience is a cautionary tale for other states, said Tarren Bragdon, CEO of the Maine Heritage Policy Center in Portland. The program missed the mark by not limiting benefits to only the uninsured, he said, and states with limited resources should consider taking a more targeted approach.

The full report is available online at www.mathematica-mpr.com/health/dirigochoice.asp

As more state policy makers consider their options for expanding health insurance coverage, the experience of Maine's Dirigo Health may offer a road map for avoiding potential missteps.

Under the Dirigo Health initiative, which began in 2005, the state offered subsidized health insurance for small businesses, self-employed workers, and low- and moderate-income individuals through a program called DirigoChoice. In addition, the state increased the annual income eligibility level for its Medicaid program, MaineCare, to include parents of children under age 19 years who were at or below 200% of the federal poverty level.

The goal behind the Dirigo Health initiative has been to provide access to affordable health coverage for every Maine resident by 2009. (“Dirigo,” part of Maine's motto, means “I direct” in Latin.)

Although the program has seen success in targeting subsidies to low-income individuals, it also has run into problems meeting its financial goals and hitting enrollment targets, according to a report commissioned by the Commonwealth Fund. The report evaluated the program as of September 2006.

“The implementation can be just as difficult as actually passing the law,” said Debra J. Lipson, the lead author of the report and a senior researcher at Mathematica Policy Research Inc., based in Washington.

When the Dirigo Health Reform Act was passed in 2003, the program was touted as a means to achieve universal access to health insurance and targeted the 136,000 uninsured Maine residents. The state estimated that in the first year of the program, it would enroll about 41,000 individuals.

But the program has fallen short of those expectations and, as of September 2006, had enrolled about 11,100 individuals in DirigoChoice. About 5,000 individuals were enrolled in the MaineCare expansion. An additional 18,100 individuals were covered through an earlier MaineCare expansion that targeted low-income childless adults.

The higher total enrollments in the two MaineCare expansions indicate that states can have success in increasing enrollment when they offer fully subsidized insurance options, the researchers concluded. But, as in the case in Maine, those expansions come with a large price tag.

Another problem for the Maine program is that DirigoChoice remains unaffordable for many small employers. About 700 small firms were enrolled in the program as of September 2006, comprising about 2.5% of all eligible small businesses. About 83% of firms that did not offer the program or any other health coverage said they failed to offer benefits because premiums were too high, according to the report.

Paying for the program also has been difficult in Maine. Most of the cost was supposed to be offset by savings from lower uncompensated care. But how savings are measured has been controversial from the start, and the program has not been able to generate enough revenue, the report said.

The savings offset payment formula even was challenged in court by insurers and the state's chamber of commerce. Although the Maine Supreme Court sided with the state in May 2007, the formula is widely viewed as “politically unsustainable in its current form,” according to the report.

The type of enrollment in the Dirigo Health program also has created funding problems for Maine. For example, enrollment by previously uninsured individuals has been lower than expected, leading to a lower reduction in charity care costs and limiting the revenues that could be raised for the program. As a result of this and other revenue shortfalls, the state has had to institute periodic enrollment freezes.

Creating affordable health insurance options was a challenge in Maine because there was little provider competition and a highly concentrated insurance market, the report noted.

In many ways the Maine experience is a cautionary tale for other states, said Tarren Bragdon, CEO of the Maine Heritage Policy Center in Portland. The program missed the mark by not limiting benefits to only the uninsured, he said, and states with limited resources should consider taking a more targeted approach.