With the ongoing debate on the cost of healthcare and the myriad of proposals to "fix" it, it's easy to become distracted from the daily operational issues that acute-care hospitals face in managing one of the fastest growing expense lines; physician preference items.

Physician preference items can end up accounting for a sizable portion of a hospital's total supply expenses. In 2008, the FDA reported that 3,370 new items were submitted for FDA approval and that number continues to climb. In fact, by 2011, the Healthcare Advisory Board predicts that 35 to 45 percent of all procedures will use an implantable device.

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Managing physician preference can be as complex as the technology that is being used. A physician's preference results from many factors, including training, relationships and outcomes. However, of the three, the one most easily measurable--outcomes--has yielded very little evidence to support one product's superiority over the other. In the absence of an implant registry, efficacy and outcomes will continue to be the ambiguous argument made in defense of physician preference.

Recently, I was talking with a colleague in the consulting field who described the work she's doing on physician preference with a large health system. She was flabbergasted to find that the hospital decided to support a physician's use of a line of implants while paying three times the GPO contracted price for the product line.

Why? Hospital administration informed her that when they presented the contracted price to the supplier, the supplier representative informed the hospital that in order to honor the GPO price, he would not be able to provide service to the surgeon in the operating room.

Hospital administrators approached the physician with the dilemma, only to hear from the physician that if the supplier representative could not provide service, the hospital would have to hire a resource to do so. Weighing the impact of added cost of goods with added full-time employees, the hospital elected to pay the premium price.

Good decision? From nine months of purchasing data, the hospital found it had paid more than $75,000 over the GPO contracted price for a single item within the supplier's extensive product line. This is not an anomaly or an isolated tale of mismanagement; it's the root cause of the escalating costs of physician preference items. Relationships are the chief driver of physician preference. Time and again we hear of physicians changing the products they prefer when the vendor sales representative changes employers.

What's the solution? The most effective approach to managing the expense of physician preference items requires the hospital, armed with credible data, to sit with physicians and discuss the financial considerations of practice variation and preference. After all, physicians are scientists, and as such, appreciate and respond to data-rich discussions (at least when it involveds data such as procedure direct margin, line item costs of equivalent products, and the cost effective practice patterns of their peers.)

Where to start? Hospitals that are paying more than 40 percent of a procedure's net revenue to the cost of implants might reevaluate the long term profitability of a physician's preference.

John Cunningham is VP, acute division, supply chain operations at Universal Health Services, Inc. He has extensive experience turning around and leading hospital supply chain operations in some of the nation's leading academic medical centers and large integrated delivery networks. In addition to his current position with UHS, John is also a member of the adjunct faculty in the Drexel University School of Nursing and Health Professions and served in the United States Navy.

I have been thinking a lot about the 2009 ACPE Doctor-Nurse Behavior Study, which surveyed 2,124 physicians and 696 nurses. It found that nearly 85 percent of respondents experienced degrading comments at work, including yelling (73 percent), cursing (49 percent) and refusing to work together (38 percent).

As I wrote in my first book, Better Communication for Better Care, confronting a physician creates fear, but in retrospect, we all benefit from early intervention to avoid lapses in patient care suffers and even burnout. The reason why I use the term "in retrospect" will become apparent after I relay my own humbling experience (from a previous century):

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I was a third-year surgical resident in the Emergency Department at a busy urban hospital. I had been on duty for 20 consecutive hours when a man who had been working on his car was brought around 3 a.m. with battery acid covering his face and eroding his skin.

Calmly, I asked the triage nurse where the nearest eye-wash station was located.

"We don't have one," she replied.

"Where is the nearest shower?" I asked.

"We don't have one," she replied.

"Then, I will take him to the changing area in the operating room (20 yards away), where they have a shower to wash the acid off."

"Dr. Cohn, our protocol does not allow an acute patient to be transported out of the ED," she countered.

That was when I lost it. Instead of saying, "Let's take care of this patient's acute needs to get the acid off his face and discuss revising the protocol in the morning," I let her know what I thought about her protocol and took the patient to the OR changing room shower.

When I returned with the patient, I learned that I had been reported on for swearing at a nurse in front of a patient. I counted at least five bleary-eyed administrators with clipboards taking statements from the triage nurse and everyone else who had been nearby.

I cannot remember the number of times that I apologized for my behavior and how many times I was admonished and reminded about how, in times of crisis, the team leader needs to remain calm. I felt that my behavior was under a microscope for the next year. It was truly a low point of my residency.

I responded by changing my behavior and relating that humbling incident to teach incoming residents why they should not fight at night.

A few decades later, I learned about Marshall Rosenberg's Four-Step Model on how to give and receive feedback in conflict situations. I summarized it in a chapter of my book entitled, "What Physicians and Administrators Can Learn from Nurses" as follows:

1) Observation: "Yesterday, there was a problem with..."
2) Emotional response: "I am feeling concerned about..."
3) Needs: "Because I need..."
4) Request: "In the future, would you be willing to...?"

I feel that the predominant leadership behavior I witnessed during medical school and residency centered on command-and-control, win-lose interactions. Not until MBA school did I learn that women are socialized to value relationships and that leadership styles described by Daniel Goleman that involve vision, coaching, and democratic and affiliative approaches build teamwork better than the approaches I had witnessed.

As the current ACPE CEO Barry Silbaugh wrote: "Because of our traditional roles in the health care hierarchy...physicians need to be role models of effective teamwork and leadership under stress for physicians in training, for other members of the healthcare team, and for our patients."

What do you think?

* Do you agree with Goleman that emotional intelligence matters at least as much as IQ in predicting career success?

* Do you believe that conversations can be our most effective weapon in eliminating disruptive behavior among healthcare personnel, as described by Joseph Grenny in a manuscript that accompanied the ACPE study, entitled "Crucial Conversations: The Most Potent Force for Eliminating Disruptive Behavior"?

* Finally, do you agree with the seriousness of this problem, as exemplified by the 2005 report Silence Kills, in which more than half of the healthcare workers surveyed witnessed coworkers break rules, make mistakes, fail to support, demonstrate incompetence, show poor teamwork, disrespect them, and micromanage, and yet only 10 percent felt confident of their ability to raise concerns with co-workers?

I welcome your thoughts and comments.

Ken Cohn is a practicing general surgeon/MBA who divides his time between providing general surgical coverage and speaking, writing, teaching, and consulting on physician-hospital relations.

I recently learned about an online medical practice that uses the Internet to connect with and take care of patients. I was intrigued by what I heard, so I researched the site further and found it to be a very interesting concept.

Through the site, patients use the Internet as a primary means of communication with their healthcare provider. They create an account where their healthcare information will be stored and then have access to multiple physicians at a click of the mouse.

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It's an interesting concept in that each patient's interaction with his or her provider takes place through the Internet (via instant messaging, video or email).

For example, a patient who wakes up feeling ill may they log into his account and schedule a cyber "appointment" with a physician. The physician would log on, review the information provided and discuss the patient's symptoms via the Internet. Depending upon the results of the conversation, several things may occur next: 1) An in-person appointment might be scheduled; 2) The physician would call in a prescription for the patient to pick up at a later time; or 3) Another regimen of care is provided, with a follow-up appointment necessary to ensure the patient is on the mend.

Using an online account, patients identify physicians with whom they'll establish a relationship as part of their own personalized "care team."

The website touts the significant savings in time for these patients--specifically the amount of time that is saved by not waiting in the ED or physician's offices. I expect, too, that there are cost savings by doing much of the physician-patient interaction via the Internet.

Additionally, physicians signed on with the site are not part of insurance plans, so most of the cost is out of pocket (unless the patient has insurance plans that allow for "out of network" visits).

If you take a close view of the this website, you'll notice that it has signed on with physicians in only a few markets, including areas of York and California. This may or may not be a deterrent, however, since so much of the patient/physician interaction takes place via the web.

This unique company has been in existence for only about a year, so it's too early to tell how this model might play into our national healthcare debate. However, I can see how this innovative approach might be very attractive to many physicians and patients alike, and at the very least offers another option for patients seeking healthcare.

I'm curious to hear what you think, though. Is this kind of web-based interaction a potential avenue for healthcare in the future?

-- Christopher Cornue is the former CEO of McKee Medical Center in northern Colorado, served as vice president at Mount Sinai Hospital Medical Center in Chicago, and has held several leadership roles at the University of Chicago Hospitals.

FierceHealthcare recently reported on the latest report that identifies the best-performing hospitals that offer the highest quality of care. The research firm that came up with the list says it's the "first comprehensive index to compare the value of care that hospitals provide."

They measure quality, including CMS's Core Measures, patient safety, mortality and readmission rates; efficiency, including the relative measure of the cost to the hospital for providing services; affordability, a relative comparison of prices charged for inpatient and outpatient services; and patient satisfaction as measured by CMS' patient satisfaction survey (known as HCAHPS).

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From a cursory view, this latest ranking list does appear to be the most rigorous I've seen. That said, this whole arena of consumerism and health leaves me baffled. And I'm sure I'm not alone.

For instance, on the one hand, there's a popular magazine rating hospitals and hospitals hanging on to every word they publish (U.S. News and World Report). And on the other hand, we also have patient satisfaction data from Health Grades, the Joint Commission, CMS, and even Angie's list. Talk about confusing the public!

How about coming up with just one authoritative list that consumers could use to help them choose a hospital, physician, home health agency, nursing home, etc.?

And while we're at it, it would also be great if providers would stop adding to the confusion with their myriad of mass media mania touting their latest score in the latest hot list.

Finally, let's take a second look at the data collection tools themselves. Have you ever read any of the HCAHPS questions? For example, one question asks, "During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?" Another question asks, "How often did nurses treat you with courtesy and respect?"

They're rather broad and vague, wouldn't you say? And when you have hospitals scoring fairly close in the results--my hospital scores a 94, while my competitor scores a 92, for instance--there is no real "meat," in my estimation, for the public to actually gauge which hospital truly provided a better patient experience and thus, higher satisfaction.

If you believe the scores, hospital experiences are pretty peachy keen. But talk to a neighbor who just experienced the system and you'll hear a different story that causes you to wonder where these scores really came from.

Of course all of the rating agencies have a business interest to do so. Arriving at one standard will be quite impossible unless perhaps they all put their heads together to see how their data complements one another and work together to actually help the public.

People do not pay attention to this data until there is a crisis. Even then, they may review the data hastily, without a clear understanding of how to use it or which data is the most accurate. I have witnessed this firsthand during my sister's recent bout with breast cancer. Hospitals need to educate people around these issues, too--rather than advertise their patient satisfaction scores to compete with neighboring institutions.

What is interesting is even with the educated boomer consumer, perceptions of hospitals span decades. If your local hospital was "the place where my grandmother died," chances are you're not going to step foot in there as a patient if you can help it. Funny how that works.

So what do you think? Do we need to come up with one solid way to measure and report quality and satisfaction versus just satisfaction alone? I'd love to hear your thoughts!

Anthony Cirillo, FACHE, ABC, is president of Fast Forward Consulting, which specializes in patient- and person-centered care and strategic marketing for healthcare facilities.

The CEO of a Cambridge, Mass.-based hospital recently wrote a great blog post about how his own health issues have impacted his views of healthcare reform.

"The true promise of health care reform is a transformation to a system that prevents disease more than it treats it," Dennis D. Keefe, CEO of Cambridge Health Alliance, writes for WBUR, a Boston-based National Public Radio affiliate. "There's plenty of money in the system, we just aren't spending it correctly, or aiming it at the programs that produce the best results."

Noting how the proactive steps he has taken to control his diabetes has resulted in fewer medications and trips to his doctor's office, he writes that while "it may seem strange for a hospital CEO to be envisioning declining patient volumes...that's the point. If we are to really succeed with reform that lowers costs as well as improves outcomes, physicians and other clinicians will have to become health educators and hospitals and clinics will be wellness centers."

You can read the rest on WBUR's website.

If you work at a hospital, you know these institutions are pretty traditional when it comes to modes of communications. And now there's the brave new world of social media thrown into the mix. If you've already dipped your toes into the water, bravo!

If your organization is still on the fence, you'll likely meet up with a few nervous naysayers who, understandably, have concerns. Here are a few ways to alleviate their apprehension:

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We could be sued! Your legal and risk management folks very likely can tick off a lengthy list of potential liabilities that exist in the social media world. You'll hear words such as slander, libel and even a new term--"twible" (defamation made through a Twitter account) and their potential for lawsuits. Of course their concerns are valid, so how do you work through them?

At Lifespan, we worked with our legal and risk management department to discuss these potential threats and recognize they are out there. At the same time, the facts of social media must be discussed--the rapid increase in the use of this technology for communication is first and foremost and the numbers speak for themselves. More and more people--including your patients, staff, and competitors--are diving into the waters of social media and talking about you. If the chatter is good--fantastic. If it's bad, address it through these methods, and take larger steps if necessary.

There's always the chance of lawsuits--but this is true of any industry. But does the fear of malpractice lawsuits stop our physicians from practicing medicine? No. And having your legal department on board with this new vehicle of communication will help them be aware of the realities of social media.

The website LegalTechnology has a whole section dedicated to just this topic. There's also a great report out there by Russell Herder and Ethos Business Law that discusses all these issues. Should you be concerned? Yes. Should it stop you from building a brand loyalty and reaching out to people through the fastest-growing mode of communication? Definitely not.

What is someone violates our corporate standards? HR may be concerned about violations of corporate standards and your corporate compliance policy. Rightly so, but there are conversations happening in hallways, break rooms and elevators every day that you might never hear.

These same types of conversations are also taking place in the social media sphere, allowing you to monitor them and even be part of them. Get HR involved early on, help them understand that this is just another form of communication, and all the same rules apply, and then have a plan in place to communicate to staff.

Our firewalls won't allow it. If your organization is like ours, IT is a high priority and firewalls are in place--all for good reason. But that protection can create a nightmare when trying to access blocked sites like Facebook and YouTube when you begin to implement a social media presence. It's vital to get your IT folks on board beforehand so you'll have access to the sites you need.

This will invariably bring up another issue--now that you've entered the world of social media, do you have your staff come on board with you, or will social networking sites remain inaccessible from computers within the hospital? (Of course you can't forget about mobile devices that already provide access anyway!) A recent blog post by Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston, addresses this issue.

All of these issues are warranted, especially when we are in the business of providing healthcare and we are held to the strictest standards in protected health information. So what do you do? Build a plan that includes the development of policies and guidelines.

Develop a policy: Even if you've already become part of the social media world, it's not too late to develop policies that will serve as a guide for your employees. It's also good to let your fans and followers know what your public policy is.

If you don't know where to start, there are plenty of sample policies out there to help you mold your own. You can even find them with one simple search in Twitter, because the "tweeps" (those who follow others on Twitter) out there are always so helpful. (Another reason to enter social media--information at your fingertips!)

Here's the bottom line: People will be talking about you and your hospital in the world of social media. If you're not involved, you'll never know what's being said, and you certainly can't respond. So it's better to see the obstacles and work your way through them to be part of this new mode of communication. The rewards definitely outweigh the risks.

Nancy Cawley Jean blogs regularly about social media for Hospital Impact. She is a senior media relations officer for Lifespan, a five-hospital system in Rhode Island. A communications and media relations specialist, she manages the national media relations for research at Rhode Island Hospital and Hasbro Children's Hospital, in Providence, and oversees social media for Lifespan.

In my last post for Hospital Impact, I spoke of the possibility of standards-based meaningful use criteria, and performance-based meaningful use, such as recording the number of smokers enrolled in cessation. Hidden beneath these regulations are a whole other set of compliance standards that are yet to be discussed: internal controls.

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When you hear the term 'internal controls,' you may think of them in terms of the financial industry's Sarbanes-Oxley (SOX) compliance. However, internal controls have also manifested within the healthcare and life sciences industries. HIPAA deals with internal controls in the concept of how privacy is protected. The FDA regulation, 21 CFR Part 11, takes into account internal controls by requiring audit trails on access to GMP data stored electronically.

Internal controls will ultimately be required for meaningful use compliance, especially the performance-based regulations. For instance, if a provider must report the number of smokers enrolled in a cessation class, how can it verify whether the number is accurate? Although there is no way to be 100 percent certain, internal controls could help improve the certainty. Audit trails and electronic signatures can verify who accessed the files. Standard Operating Procedures can confirm whether those individuals have authority to adjust the enrollment number. Then, training records can confirm if those individuals understand what those enrollment numbers represent.

The need for providers to establish a meaningful use compliance framework is not a question of "if," but rather a question of "when." Providers must begin thinking in terms of standards, performance and internal controls.

Joseph Ingemi is a blogger, Certified Information Systems Auditor, and certified Project Management Professional who writes about healthcare IT issues. He also consults on healthcare IT issues through his company, Pinarus Technologies.

FierceHealthFinance: Based on the experiences of your member hospitals, what is your global forecast for hospitals nationwide in 2010 as the national RAC program ramps up?

Rueben: Florida, like New York and California, served as the initial testing ground for the Centers for Medicare and Medicaid Services to develop the RAC program.

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For example, the demonstration RACs could look back four years, but in the national program CMS has limited the look-back period to three years past the claim paid date, as well as setting a maximum look-back date of Oct. 1, 2007. In addition, CMS has limited the amount of information that the national RACs can collect without good reason. The RACs won't be able to conduct either automated or complex medical reviews of more than 10 records without obtaining CMS approval via a new issue review process and identifying all approved issues for review on their websites. And even with this, there is now a limit on the number of records that can be requested every 45 days.

Much debate and wringing of the hands occurred nationally as the demonstration unfolded in the test states. These and other changes to the national program mean that hospitals around the country can breathe easier about RAC implementation in 2010 and beyond. That said, hospitals certainly need to take the program very seriously and prepare for national implementation.

FHF: If CMS holds to its current timetable, hospitals could begin seeing complex reviews for DRG (diagnosis-related groups) validation and coding errors by the end of the year, and for medical necessity in 2010. Based on Florida's experiences with complex reviews in the demonstration, what should hospitals expect?

Rueben: In complex reviews, the RACs are looking for claims that aren't substantiated. It is up to the hospital to ensure that physicians provide documentation that adequately substantiates coding, DRG assignment, and medical necessity of services. Hospitals in Florida have worked to develop billing systems that will help them avoid having claims pulled in the first place and documentation systems that will substantiate any claims that do get pulled by a RAC. Hospitals must understand that they have to get it right the first time if they want to avoid extra bureaucratic burdens.

FHF: What do you foresee as the biggest misunderstanding about the appeals process in the national RAC program?

Rueben: With a program like this, the contractors get very ambitious in terms of the claims that they feel should be disallowed. So I anticipate a continued aggressive approach from the RACs and a lot of claims being flagged initially. However, I also expect many of those claims to end up being paid--if the hospitals appeal. At some Florida hospitals, we have found that as many as 75 to 80 percent of the claims that were first recouped are now being paid.

Interview conducted by Caralyn Davis.

FierceHealthcare: Do you have a prediction, or even a personal preference, as to what type of insurance model is going to work?

Paul Levy: The approach we're using in Massachusetts which, I think works pretty well, basically requires people to have insurance--in other words, there's a personal mandate that you have to have insurance, and then the state has created an insurance exchange. The insurance companies in the state have to live by the rules of that exchange and provide the insurance coverage, and then subsidies exist for the lower income people. I think that's a pretty practical way to do it.

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The Netherlands has a similar kind of approach where there's a requirement to have insurance, insurers are required to take anybody who wants insurance, and they use the private companies to do that. The alternative approach is to have a public option alongside those private insurers. I don't personally favor that one, because I think the other one can work as effectively, if not more so.

FH: From your comments, I take it that directly government-funded schemes--like a Medicare for all, or even single-payer--are not something that you favor?

PL: That's right. I don't like the idea, just personally, of the government controlling the broad base of health insurance in the country. I recognize that it does so with regard to Medicare--that's a particular population group--but I think for the broad base of the population, I'd prefer to rely on the private markets to do that.

FH: What effect has the Massachusetts reform scheme had on your institution?

PL: It has had very little effect. It's re-categorized some people who used to be free-care patients, to now being on an insurance plan. Financially for the hospitals, it has had very little effect because we used to get some payment through the free-care system to pay for the free-care patients, and now we get some payment through the insurance system to pay for those same patients. So overall, I think it hasn't had a big effect on the hospitals, generally.

FH: But that might not be the case in other states where, perhaps, there's not a free-care fund of any substance?

PL: That could be, but I'm not that familiar with other states. The thing with legislation is, there are always unintended consequences. I've always thought that you shouldn't make major global changes in this field. You should work on the edges and make incremental changes. But that's my personal view about how public policy should be done.

FH: Are there any issues in your mind that are so hot right now that incremental change won't do the job?

PL: I think the answer there lies with the public, and what their concerns are. I think people who currently have insurance are mainly worried about what happens if they change their job or lose their job, or if they have a pre-existing condition and they have to change insurance companies. That's why I think changing the overall regulatory scheme around insurance companies is important. The second thing is, there should be some system in place where everybody can have insurance. To me, those are the two major things, and I would focus on those.

FH: What impact--again, if any--do you think changes like mandated insurance coverage would have in a facility? It sounds like you're saying probably none at all.

PL: In our case, we're kind of ahead of the curve in Massachusetts. A lot of those changes have already happened here, so the question is, to what extent can they happen elsewhere, and be done in a way that doesn't have unintended consequences.

FH: Have there been observable, unintended consequences in Massachusetts? For example, one of your local daily newspapers reports that the wait for a primary-care doctor in the Boston metro area has jumped.

PL: I don't know if that's true. I've read stories in both directions. I just don't know.

FH: In your opinion, do you see any areas in which a system, other than in a primary-care capacity, may have trouble absorbing ranks of newly insured. Are there any other stress points you're anticipating?

PL: I haven't seen real stress points here, no. Remember, we had a very small percentage of the population who did not have insurance. There are other states that have a bigger percentage. So it may be different.

FH: Have you seen people who are not acutely sick appearing in your EDs?

PL: That's always been the case. And it's not clear how much of that has been related to having insurance versus not having insurance. I'm not sure I can really give you a complete answer to the cause of that. I'm not sure if there’s been an increase or a decrease. I think it varies, and if there is an increase or decrease, it's also hard to quantify the reasons. Sometimes it's because people actually have insurance, but they've been going to a primary-care doctor who says 'Go to the emergency room.'

FH: One question about Massachusetts: What are the unintended consequences of perhaps the market reactions to the mandated coverage issue? While people with, say, chronic illnesses can still get insurance, but there will be traps billed into the insurance that still make it very hard to use and the insurance companies will still win, somehow in terms of denying care, just in a different way.

PL: You do need to regulate the companies to ensure you don't get unintended consequences. There's a question there as to what extent the federal government is willing to take over that regulatory function from the states. That's an issue that Congress has to deal with.

FH: Do you think systematic health reform is really needed?

PL: Well, the use of the word reform is always problematic because one person's reform is one person's reverse. I think what's really needed is a movement to provide as many people as possible with insurance so they can get access to preventative care and primary care and the like. That kind of change, in terms of insurance coverage, I think has to occur at a national level.

There are a few parts of this that would be helpful. One, which I believe is in almost every bill that's been proposed so far, is changes in the rules so that insurance companies cannot deny coverage to people because of pre-existing conditions, and other provisions like that which make it difficult to get insurance. That does take a change in national law, because right now the insurance industry is regulated in several states, and there's wide variation in those rules.

For example, insurance companies in Massachusetts are not allowed to use pre-existing conditions as an exclusion. I'm hard-pressed to find anyone who disagrees with that kind of regulatory change, and I'm hoping that that survives all of these different bills.

The next question is, how do you provide insurance to all members of a population? And here, obviously, you have to make it available, but also, a large number of people can't afford it. So some kind of subsidy is required. This gets to the nub of the problem in Washington, which is that if you provide a subsidy to one group of people, someone has to pay for that. And the forum--how that payment takes place--is a major political fight, because when you are creating a new subsidy, you're taking money away from some other group in some other way. That's a traditional political problem that Congress and the president have to face--what's the best way to finance a national mandate?

A lot of the discussion in Washington right now is about that issue. The degree to which Congress is willing to do some kind of broad-based tax is directly correlated to the degree in which they want to provide a subsidy; which is to say, the more subsidies you offer, the more money you have to raise, and the more money you have to raise, the broader the tax vehicle. If you have a very narrow tax plan, it can't raise as much money as you otherwise would want.

That, I view as the major political battle going on in Washington right now, and I think it's one that will be hard to work out.

FH: What do you think would happen if the entire souffle of health reform collapsed, and nothing changed?

PL: It's inconceivable that that would happen. Something will pass, and the world will be better for it.

Interview by Anne Zieger, senior editor, FierceHealthcare and FierceHealthFinance.