[ Home ] [ Up ] [ Classes ] [ Registration ] [ Search ] [ New News ] [ CME Tests ] [ Evaluation ]

NEW NEWS - CLASS 9

7-15-07    Ann Arbor, Mich.-based College of Healthcare Information Management Executives

According to a Web site poll for members of the Ann Arbor, Mich.-based College of Healthcare Information Management, even when healthcare organizations have implemented electronic medical-record systems, most executives continue to print out paper copies of reports.  Of those responding, 59% said laboratory reports continue to be printed and distributed on paper; 54% said imaging reports are printed and distributed; and 55% print and distribute paper health information management reports.  Reasons for this include “Shouldn’t but do,” “Old habits die hard!” “Trying to wean them off,”  “Old school docs still want them faxed.”  Additional reasons include:

The poll was posted on CHIME’s website [http://www.cio-chime.org"] accessible only to the organization’s 1,100 members with 83 people responding.  In another poll, which had 126 respondents, 40% said they had an EMR in use, another 40% were in the implementation phase, and 14% were in the process of selecting an EMR.  (Modern Healthcare's Daily Dose, 7-13-07)

Flaws of safety tracking system - Reports of diabetes-drug side effects triple
Reports of side effects to federal regulators tripled regarding possible heart risks from the diabetes drug Avandia, may be a sign that doctors were unaware of the drug’s possible role in their patients’ heart problems and may not have reported many such cases in the past. It shows the flaws of the safety tracking system and suggests that a better one might have detected a potential problem before the drug had been on the market for eight years.  (Modern Healthcare's Daily Dose, 7-13-07)

Employer Perspective

Sears retiree health care costs

Sears Holdings Corp. retiree health care costs amounted to around 17% of Sears Roebuck's operating income last year and Sears claims it needs to cut costs to be more competitive.  Sears retirees who are under age 65, about 15% of Sears retirees, will have to pay for their own health care coverage as the retailer struggles to rein in soaring costs.  Sears is one of the only major U.S. retailers that provides retiree health care coverage. (Source:  Crain's Chicago Business, 9-22-05)

Employer Perspective/ Premiums Increase

Employer-sponsored health insurance rates rose an average of 11.2% in 2004 per a study released by the Kaiser Family Foundation and Health Research and Educational Trust.  The study found that since 2001, the cost of health insurance has risen a total of 59%; employee contributions increased 57% to an average of $558 for individual coverage and 49% to $2,661 for family coverage during the same period, even as workers' wages rose just 12%.  

The 2004 Annual Employer Health Benefits Survey includes responses from more than 3,000 companies of all sizes, also found that the percentage of workers receiving health coverage from their employer dropped to 61% in 2004 from 65% in 2001, a difference of about 5 million jobs. The study found cost-sharing increased "modestly" in 2004, though the percentage of covered workers facing a 20% copayment for a doctor visit rose to 27% from 19% in 2003. 

Among companies with 200 or more employees, 52% said they were very likely to increase employee contributions next year. In contrast, only 15% of companies with fewer than 200 employers said they were very likely to do so. Fifty-six percent of all firms offering coverage said they had looked to save costs by shopping for new insurance options in the past year; 31% of them reported changing carriers; and 34% reported changing the type of health plan offered.  (Modern Healthcare Alert, 9-9-04)

A Small Employers Creative Solution to Increasing Premiums

To avert a 20% increase, or $8,000 in all, in health insurance premium a small employer in Massachusetts raised the deductible for hospital stays that his 17 covered employees must pay from $500 to $1,000 and offers to pay the $500 if an employee is admitted to the hospital. Even if 16 people need such care, he would break even, and for every number below that he would save $500.  (Modern Healthcare 8-26-04)

Illinois Health Facilities Board

Illinois has been investigating whether or not it should maintain the Illinois Health Facilities Board or dissolve it.  Board approval is needed for any hospital construction project in Illinois.  Those in favor of maintaining the board claim it is an efficient way to ensure the necessity for hospitals to be built in Illinois and avoid duplication of services by hospitals in close proximity to each other.  Those against having such a board are in favor of free market and competition and find the board to be bureaucratic and perhaps self serving. 

Mercy Health System of Wisconsin application to build a hospital in Crystal Lake was turned down in December by the former Illinois Health Facilities Board using a state evaluation of the projects pointing to other hospitals near the site; but in April the board approved the application when it was re-brought to the board in which during the Mercy vote a board member, Stuart Levine, whispered to another board member and then that board member changed his vote to yes giving the project the votes needed to pass.   After hearing about the meeting, local legislators called for an investigation but this was called off because a federal investigation was already in progress.  Levine was named as a defendant in a federal whistleblower lawsuit filed by Edward Hospital in Naperville over their Plainfield hospital project in which Edward officials alleged in the suit that the planning board would reject their application unless Bear Stearns & Co was used to finance the project and Deerfield contractor Jacob Kiferbaum was used to build it.  Legislators overhauled the board.  

The Illinois Health Facilities Board has been revamped to be a five member health board from a previous nine-member health board and replace it with a new five-member panel and currently consists of three members, a quorum to conduct business, chaired by former U.S. Rep. Glenn Poshard, Pamela Woodward (Morgan Stanley executive) and Susana Lopatka (Chicago nurse and former consultant at the state Department of Human Services).  More than $1.25 billion in hospital construction projects and health care transactions have been held up during the wait for the governor to name the new panel. (Crain's Chicago Business, 9-22-04)

According to an article, "New Board to Review 4 Hospital Plans", by Crystal Yednak, Chicago Tribune (section 2, page 3, October 18, 2004):  Other than the Mercy Health System of Wisconsin for a $81 million hospital in Crystal Lake, the Illinois Health Facilities Board hopes to vote on projects at November 4 meeting including:   (1) Advocate Health Care for $22 million, 144 bed hospital in Tinely Park, (2) St Francis Hospital & Health Center for $193 million, 130 bed hospital in Orland Park, (3) Edward Hospital in Naperville for $169 million 146 bed hospital in Plainfield, (4) Adventist Health System for $152 million 138 bed hospital in Bolingbrook. 

Status of Medicaid in Illinois

Illinois $9.9 billion Medicaid health insurance program for the poor covering 1.7 million Illinois residents is having difficulty controlling spending with its costs rising at least 7% a year.  A solution most agree on is to get disease management firms involved in identifying wasteful Medicaid spending and ways for the chronically ill patients to receive medical care earlier in order to avoid costlier surgeries or hospitalizations.  Health plans appear to favor Medicaid HMOs while hospitals and consumers do not.  

The current voluntary Medicaid managed care system has not been popular with Medicaid patients.  About 9% of the Illinois Medicaid recipients, about 161,000 patients, are enrolled in a few participating HMOs.  Some HMOs are suggesting an affirmative choice model used in other states and claim Illinois would save $1.5 billion over 10 years.  Critics of HMOs claim the state's fee-for-service system is doing better than private plans at controlling costs per a report by Hewitt Associates  in which employer paid private health plans is said to have a cost increase of 11% or more next year.

Providers claim the state should increase payments to primary care doctors and outpatient clinics to increase access as many doctors and clinics in recent years stopped accepting Medicaid patients because of the state's low payments. (source:  "Illinois May Hire Medicaid Adviser" subtitle "Seeks to Control Escalating Costs" by Bruce Jaspen, Chicago Tribune, Section 4, pages 1 & 6 (October 18, 2004).

UNINSURED POPULATION

Uninsured Population in 2003 Per U.S. Census Bureau

According to the U.S. Census Bureau the number of uninsured in the U.S. reached 45 million in 2003, a 3.2% increase over the 43.6 million people without insurance in 2002.  A decline in coverage by employer-sponsored plans is mostly
responsible for the overall drop in coverage.  The percentage and number of people covered by their employers fell to 60.4%, or 174 million people in 2003 from 61.3%, or 175.3 million people in 2002. Hispanics continued last year to be the least insured
of any ethnic group at 32.7%, unchanged from 2002. (Modern Healthcare 8-26-04)

California Proposed Legislation to help Uninsured/ Class Actions Against Hospitals

Nationwide, debate over how much the uninsured are charged and the aggressive actions some hospitals have taken to collect unpaid bills prompted voluntary changes in hospital policies and some class-action lawsuits against nearly 400 hospitals. Prices charged to the uninsured are high because they don't have insurers or government programs to negotiate discounts for them. A bill to deal with this issued passed the Senate in California and is opposed by the California Healthcare Association.  (Modern Healthcare 8-26-04)

Hospital Provider perspective 

Tenet Healthcare Corp., Santa Barbara, Calif., said it will take a $200 million to $225 million charge in the third quarter to reflect increased bad debt caused by an accounting change, higher numbers of uninsured patients and scraps with insurers.  Tenet owns and operates 112 hospitals.  (Modern Healthcare 10/22/03 )

Uninsured Population

According to a study by the Commonwealth Fund almost one-third of uninsured U.S. workers are employed by large companies, the employers traditionally most likely to offer health insurance coverage to their workers.  The study found the percentage of uninsured workers employed by companies with more than 500 employees rose to 32% in 2001 from 25% in 1987.  As of 2001, a quarter of all uninsured Americans
worked for or were dependents of workers at large companies.  According to the U.S. Census Bureau between 2000 and 2002, the ranks of the uninsured rose 10% to nearly 43.6 million.  (Modern Healthcare 10/22/03)

Caring for the Uninsured & Underinsured

Community Catalyst suggests states should adopt legislation to guarantee
not-for-profit hospitals provide care to the uninsured and underinsured. (Modern Healthcare 10/29/03)

Proposed Plan for the Uninsured

According to the U.S. Census Bureau an estimated 43.6 million Americans were uninsured in 2002.  Democratic presidential candidate Wesley Clark unveiled a 10-year, $695 billion healthcare proposal that would mandate all parents buy health insurance for their children up to age 22 and would provide federal funding to extend state health insurance programs such as Medicaid to adults earning less than 150% of the poverty level (Modern Healthcare 10/28/03)  

10-2-02:  Per Modern Healthcare (9-30-02):  41.2 million Americans or 14.6% of the U.S. population were without health insurance coverage last year as compared to 39.8 million uninsured in 2000.

INSURER/ MANAGED CARE ORGANIZATION PERSPECTIVE

Grants from HHS to Help States Create High Risk Insurance Pools

A high-risk pool typically is a state-created non-profit association that offers health insurance to individuals with pre-existing health conditions.  Enrollment in these pools is growing, with over 172,000 individuals enrolled in risk pools nationwide.  South Dakota began enrolling people in its high-risk pool on August 1, 2003.  Maryland's high-risk pool has been operating since July 1, 2003.

Medicare Competition - Alternatives?

Bush is suggesting seniors must have choices other than traditional Medicare to prompt competition.  (Modern Healthcare 10/29/03 )  

PROVIDER PERSPECTIVE

Hospitals Partner for regional response to man-made or natural disasters

Three hospitals in the Washington metro area formed a partnership to improve and coordinate their responses to disasters.  The partnership leaders say coordinated collaboration and capitalizing on complementary strengths are essential to an effective regional response to man-made or natural disasters.

Partnership goals include:

-- Assuring that each institution can respond rapidly and effectively to any
emergency situation;

-- Providing streamlined integration of the responses of the three partner
institutions with other community, regional, and national emergency plans;
and

-- Establishing a model for other federal and private sector hospitals to
form similar partnerships.

-- Top managers from the partner hospitals have been meeting for several months
and teams have been established to address key issues. (NIH News 10-13-04)

Investigations of Non-Profit Tax Exempt Hospitals

Chief Tax Counsel for the House Ways and Means Committee told attendees at the American Health Lawyers' Tax Issues for Healthcare Organizations program that the committee will continue investigating non-profit tax exempt organizations, particularly tax exempt hospitals and healthcare organizations in how and why some organizations have tax exemptions, tax implications of charitable donations of healthcare patents and related intellectual property information. (Health law Highlights 10-25-04)

Laying off Doctors in NY

Up to 40 doctors working for Nassau Health Care Corp., East Meadow , N.Y. , will be let go because of unanticipated cost increases in the New York state retirement program.  The public agency, which runs 1,370-bed Nassau University Medical Center , seven community health centers and an extended-care facility, expected to pay $1.5 million in pension costs this year but was hit with a $10 million bill.  (Modern Healthcare 10/28/03 )

Converting Hospital into Inpatient Behavioral Health Hospital to Solve Financial Ills

Three-hospital Pittsburgh Mercy Health System said it is seeking local, state and federal approval to eventually stop operating 132-bed Mercy Providence Hospital, Pittsburgh, as a general acute-care facility and covert it into an inpatient behavioral health hospital.  The plan calls for eventually closing all general inpatient services, including emergency care. Outpatient services would remain open.   (Modern Healthcare 10/28/03 )

For Guidelines on Web design used as an authoritative source to design federal websites see:  http://usability.gov/pdfs/guidelines.html

Proposed Merger to Create Largest Health Insurer

Anthem, Indianapolis , has agreed to acquire larger rival WellPoint Health Networks, Thousand Oaks , Calif. , for about $15.2 billion in cash and stock in a deal that would bring 13 Blues plans under the umbrella of a single corporate entity. The merger would create the nation's largest health insurer with 26 million enrollees.  The new company, to be called WellPoint Inc., is to be headquartered in Indianapolis .  Current industry leader is UnitedHealth Group, Minneapolis , which covers about 17.2 million members.  Additionally, UnitedHealth agreed to acquired Mid Atlantic Medical Services, Rockville, Md., in a $2.95 billion deal that would give the combined company a leading position in the fast-growing mid-Atlantic region (Modern Healthcare 10/27/03)

Residency Program Accreditation Issues

Martin Luther King Jr./Drew Medical Center , Los Angeles , 261-bed teaching hospital, recently received an unfavorable assessment from the Accreditation Council for Graduate Medical Education, which said it was moving toward shutting all 18 of the hospital's residency programs. The hospital, which can appeal the rating, already has been ordered to close surgery and radiology residency programs.  (Modern Healthcare 10/24/03 )

AMA Sings Deal with Henry Ford Medical Group

The American Medical Association signed a three-year agreement that provides discounted annual dues to about 700 physicians at the Henry Ford Medical Group in Detroit in order to build membership after a decline of 11.3%, or about 33,200 members, since 1999.  The multispecialty medical group will underwrite dues for its physicians, paying the AMA about $300 per year per membership, compared with the standard annual fee of $420 for full membership.  Before the discount, 126 of the group's 702 full-time doctors were AMA members.  (Modern Healthcare 10/24/03 )

ETHICS:  Providers For Charging No Shows

More practices are beginning to charge for patients missing appointments. 

Some groups double-book at certain points of the day, though that can help perpetuate missed appointments because patients become irritated with waiting a long time to see the doctor.

Many practices hang the threat of a charge out there and if a patient misses one appointment but shows up the next time, the practice issues a warning and waives the fee.

AMA policy states that a physician may charge a patient for a missed appointment, or for one not cancelled 24 hours in advance, if the patient is fully advised the physician will make such a charge. (American Medical News 10-25-04)

http://www.ama-assn.org/amednews/2004/11/01/bisa1101.htm

Per Modern Healthcare (2-24-03):  According to a study by conducted by the actuarial firm Milliman USA, Seattle, Blue Cross and Blue Shield Association, Chicago, had a decline in the percentage of health insurance premium revenue going toward payment of medical claims. The study is the latest in a series of Blues commissioned reports analyzing key drivers behind rising healthcare costs.  Per the study, the percent of premium revenue devoted to covering medical costs dropped to 84.7% in 2002 from 85.7% in 2001. The industry medical cost ratio was 85.4% in 1998.  Pretax profits grew to 3.7% of premium revenue in 2002, up from 2.7% in 2001 and 1.7% in 1998. Administrative costs consumed 11.6% of health plans' premium revenue in both 2002 and 2001, down significantly from the industry's 12.9% administrative cost ratio in 1998. The report was based on data drawn from both for-profit and not-for-profit organizations and commissioned to determine trends in health plans' administrative costs. The medical cost ratio was not included in the report; it was obtained by subtracting the pretax profit ratio and the administrative cost ratio from 100%. Blues association spokesman Chris Hamrick said he confirmed that the method was the correct one to use.  Hamrick said health plans achieved an average annual 2.6% reduction in their administrative cost ratio from 1998 to 2002, largely because of greater efficiencies. The average annual growth in pretax profits as a percentage of premium revenue was 21.8% - but off of a much smaller base, Hamrick noted. "We're still only talking about less than 4 cents on every premium dollar" he said. 

Physician Work Stoppage Over Medical Malpractice Insurance 

1-6-03:  A dozen Mississippi surgeons took leaves of absence Monday to protest the high cost of malpractice insurance planning to stay off their jobs for two days to attend a malpractice seminar.  Dozens of doctors in New Jersey plan a work stoppage Feb. 3 to focus attention on demands that the state Legislature limit malpractice noneconomic damages.

1-4-03:  According to the Chicago Tribune (1-4-03), "Surgeons' Strike Over Insurance Splits W. Va." a few dozen surgeons in West Virginia's northern panhandle are in their 4th day after giving notice they would withhold their services to protest soaring medical malpractice insurance premiums like a wildcat strike or blue flu.  The surgeons gave notice that they would take a 30 day leave of absence.  This power play by the doctors is intended to force the governor and Legislature to cap the amount of malpractice awards and provide insurance premium assistance for doctors - many of whom have seen their insurance payments increase more than double since 2000.  The community has mixed feelings about the doctors action and many indicate that it is hard to be sympathetic to the doctors when they are like royalty as it is in the community.  The work stoppage is a climax of a crisis that started last year when The St. Paul Companies got out of the medical malpractice insurance business completely.  The state responded by creating its own insurer but the rates were higher than private market.

10-31-02:  According to a survey of 333 national employers by Riverwoods-based CCH Inc.:  the average cost of employee absenteeism rose almost 5% this year, up from $755 per worker in 2001to $789 per employee in 2002.  The majority used the day off to deal with family issues, personal needs, stress or because they simply felt they deserved it.  Some employers are adopting innovative strategies such as paid leave banks and compressed work weeks.  For example, with a paid leave bank, a worker can say, ‘I need two hours off a week from Thursday, but I’ll work an extra hour on Monday and Thursday to make up for it'.

RESIDENTS ISSUES

Residents 80 hour Week Passes

Per Chicago Tribune (6-21-02), "AMA OKs 80-hour Week for Residents":  The American Medical Association endorsed a new 80-hour a week work limit for medical residents for patient safety reasons.  Under the policy adopted by the AMA's House of Delegates, the association recommended residents not work more than 80 hours per week or more than 24 hours at a time, except under special circumstances.  This is nearly identical to the rules announced earlier this month by the Accreditation council for Graduate Medical Education which oversees teaching hospitals that collectively have 100,000 doctors in training.   This policy is to take effect in 2003 and hospitals that do not comply can lose their accreditation. 

Medical Residents File Class Action Lawsuit Charging Matching Program Used To
Restrain Trade

A class of about 200,000 medical residents on May 7, 2002 filed an action in
federal district court for the District of Columbia against several hospitals and healthcare associations, claiming they use the National Resident Matching Program to
keep wages low, according to a report published online in Modern Healthcare.
The lawsuit alleges the matching program results in an unreasonable restraint
of trade in violation of Sect. 1 of the Sherman Act.  
See:  http://www.modernhealthcare.com/news_briefs.php3?action=view&id=3029

5-11-02:  Per Crain's Chicago Business:  Civic Federation, a watchdog group that helped put together a coalition to formally seek bidders by the end of May to provide pharmaceutical services to 150,000 workers and dependents covered by their health plans and a similar move to seek a unified managed care provider is expected later in the year.  Participating bodies include the city of Chicago, Cook County, the Chicago Park District, the Board of Education, City Colleges of Chicago, the Chicago Housing Authority and the Chicago Transit Authority

6-21-02:  See Class 3, "New News", regarding certain hospitals in Pennsylvania OBs getting out of the practice of obstetricsdue to high cost malpractice insurance, low reimbursements, shortage of OB/GYns.

5-10-02:  Per Modern Healthcare:  The American College of Obstetricians and Gynecologists identified nine states it considers at greatest risk of facing a crisis-level shortage of OB/GYNs because of high malpractice insurance premiums:  Florida, Mississippi, Nevada, New York, Pennsylvania, Texas, Washington and West Virginia. Ohio, Oregon and Virginia.  The college said the median malpractice premium for OB/GYNs grew 167% from 1982 to 1998 and annual premiums range from $12,000 in Nebraska to $200,000-plus in Florida. In New Jersey, one of the states considered at greatest risk, hospitals report a 250% rate increase for OB/GYN coverage over the past three years. 

PATIENT PERSPECTIVE

Some Tips For Patients:

Speak up if you have questions or concerns, and if you don't understand, 
ask again.  It's your body and you have a right to know.

Pay attention to the care you are receiving.  Make sure you're getting
the right treatments and medications by the right health care
professionals.  Don't assume anything.

Educate yourself about your diagnosis, the medical tests you are
undergoing, and your treatment plan.

Ask a trusted family member or friend to be your advocate. 

Know what medications you take and why you take them.  Medication errors
are the most common health care errors.

Use a hospital, clinic, surgery center, or other type of health care
organization that has undergone a rigorous on-site evaluation against
established state-of-the-art quality and safety standards, such as that
provided by JCAHO.

Participate in all decisions about your treatment. You are the center of
the health care team.

Per HHS (85-02):  A $2.5 million contract was awarded by HHS to the Washington Hospital Center to not only substantially improve the hospital's emergency readiness capability to better serve the National Capital Region in case of a terrorist attack or any incident involving mass casualties but also serve as a model for the nation's hospitals.  Washington Hospital Center is the largest hospital in the District of Columbia with the District's biggest trauma center and busiest emergency room.  Since 2001, Washington Hospital Center has been a key part of Project ER One, an HHS-funded national effort to develop the design features for an
all-risk ready emergency department with the capabilities to manage the
medical consequences of terrorism.  The multipurpose design will allow medical staff to configure the new space in response to a variety of emergencies and other purposes. Some of the new functions include:

Per Modern Healthcare (6-19-02):    In order to get more lobbying power with declining membership, the he American Medical Association (AMA) - which now has a membership of 278,000, less than 30% of all practicing U.S. physicians, the AMA's 550-member House of Delegates yesterday after nearly three hours of debate took the first step toward converting the AMA into an umbrella group made up of other medical societies and organizations instead of individual physicians. The delegates overwhelmingly approved the creation of a committee to develop a business plan for the redesign and the plan would be considered at the AMA's annual meeting next June in Chicago. The AMA would be a more powerful lobby as an umbrella group because it would represent a far greater proportion of U.S. physicians, proponents of the plan said.  Less than one-third of practicing U.S. physicians now belong to the AMA.  As an umbrella group - an organization of organizations - the AMA would derive its membership and almost all of its dues revenue from the nation's more than 100 state medical organizations and specialty societies.  One of the delegates emphasized the importance for the AMA to study the costs involved in changing the organization.

6/6/02:  Per Modern Healthcare:  According to a survey of 140 employers by Hewitt Health Resource, health insurers are demanding premium increases averaging 22% for next year, a large increase from earlier forecasts. 

6-5-02:  Per Chicago Tribune, "Cost-Cutting Keeps AMA's Finances on Mend":  Despite a loss of membership, the American Medical Association (AMA) made money for the second year in a row by reducing by 33% travel and meeting expenses.  According to the organization's financial report, the AMA is positioned to advocate for the nation's physicians claiming a 22% increase in reserves to $193.1 million from 157 million in 2000 due to increased investment income. 

Health Plan Perspective

5-2-02  Health plans on sounder financial footing

Per Modern Healthcare (5/2/02)"Health plans' recent strategy of raising rates and forfeiting customers appears to be paying off, as several reported improved operating results, if not net income, in the first quarter. Health Net, Woodland Hills, Calif., which has been exiting unprofitable markets, boosted first-quarter net income by 17% to $49 million while enrollment dropped 2.2%. PacifiCare Health Systems, Santa Ana, Calif., lost 13% of its membership, reflecting benefit cuts and the abandonment of some Medicare markets. Without an $897 million write-off for new accounting rules, the company would have nearly tripled its bottom line to $30.1 million. For its part, Cigna Corp., Bloomfield, Conn., reported first-quarter operating income of $275 million as rate hikes helped reduce its medical-cost ratio."

5-1-02:  Oxford looks for solid 2002
Oxford Health Plans, Trumbull, Conn., serving which serves Connecticut, New Jersey and New York - struggled in the late 1990s, reported modest but better-than-expected growth for the first quarter ended March 30.  During the first quarter, Oxford's total membership--excluding recently acquired MedSpan--rose 4% to 1.57 million as it gained commercial enrollees while shedding Medicare membership. Medical costs ate up 79.9% of premium revenue, compared with 79.5% in the year-ago quarter. Its administrative cost ratio also increased slightly to 11.3% from 11.2%. The company had widely reported problems in the late 1990s, when its computer systems had difficulty keeping track of how much it owed physicians.  Source:  Modern Healthcare (5/1/02)

3/21/02    OIG Posts Audit Reports:  According to a report by the Office of Inspector General an audit was made on NYL Care and the objective of this audit was to assess whether additional benefits proposed in NYLCare's Contract Year (CY) 2000 adjusted
community rate proposal (ACRP) were available to Medicare beneficiaries at reasonable costs and as advertised, and that these benefits were both credible and properly valued. See:  A-06-00-00073 at http://oig.hhs.gov/oas/reports/region6/60000073.pdf

1/23/02:  According to the Center for Studying Health System Change (HSC) article on 1-23-02, "Blue Plans: Playing the Blues No More," by Joy M. Grossman and Bradley C. Strunk:  "Blue Cross and Blue Shield (BCBS) plans collectively insure more than one in four Americans. Since the first BCBS was founded more than 70 years ago they have been local, not-for-profit plans. However, since the mid-1990s, BCBS plans increasingly have merged and converted to for-profit, publicly traded companies. In the last several years, three large BCBS players—Anthem, Wellpoint and Health Care Service Corp.—have aggressively pursued acquisitions."  These mergers and conversions typically receive a great deal of public scrutiny. Because of the Blues' history as charitable organizations, when plans convert to for-profit status, state regulators and consumer advocates usually work to ensure charitable assets are transferred to a nonprofit entity within the state. Given the large market share of most local BCBS Plans, regulators and consumers advocates also are concerned about whether for-profit ownership will affect the accessibility and affordability of coverage in the community, particularly for hard-to-insure populations, and whether out-of-state ownership will lead to a loss of stability and local accountability."

For further information, see: from Understanding Health System Change: Local Markets, National Trends edited by Paul B. Ginsburg and Cara S. Lesser. (Chicago: Health Administration Press, 2001) 37-60.

See:    http://www.hschange.org/CONTENT/406/

Per Modern Healthcare (7-9-02):  The Health Insurance Association of America (HIAA) released research based on 1.1 million insurance policies issued by 12 HIAA member companies indicating that individual health insurance is more affordable than perceived with costs on average $1,983 annually for individuals age 40 to 44 and $3,781 for families.  The Bush administration is proposing tax credits of $1,000 per adult and $500 per child to reduce the annual cost of insurance for individuals.

12/12/01: In August, Secretary Thompson launched the Health Insurance Flexibility and Accountability (HIFA) initiative to encourage states to expand access to
health care coverage for low-income individuals through Medicaid and State
Children's Health Insurance Program (SCHIP) demonstrations.  Arizona submitted its HIFA application to HHS' Centers for Medicare & Medicaid Services (CMS) on Sept. 20 and it was approved on 12/12/01 and Arizona expects to ultimately enroll nearly 50,000 adults under the HIFA initiative, including more than 25,000 without health coverage now.   "While we want states to use the new initiative to expand health coverage to adults who otherwise would not be eligible, we also are telling states that covering children must come first," CMS Administrator Tom Scully said.  

12/3/01:  Per Amednews.com:  Aetna is expanding into North Carolina, a fast-growing state with a fast-consolidating health plan market.  Aetna has brand recognition and  so far has 225,000 members in North Carolina; Blue Cross has 2.2 million enrolled, and UnitedHealthcare has more than 700,000 members.  What Aetna finds so attractive about this market is a growing population of 8 million people, with an abundance of employers in service and technology.  Aetna saw an environment ripe for building market share because of the consolidation in the local health insurance market, four hospital-owned managed care plans have dissolved besides Blue Cross buying up Partners.

Aetna claims to have signed on nearly 750 physicians in the state.  Per the article, "AEGIS Family Health Center signed Aetna's contract in November, bringing into Aetna's PPO network 42 physicians in 12 offices in the Greensboro area. Sterling Wooten, vice president of administration for the group, said the physicians had reservations, but signing on with Aetna would help the practice keep patients as the area deals with the recent merger of Partners National Health Plans of North Carolina into Blue Cross and Blue Shield of North Carolina." and he said that "We like to participate in as many plans as we can to keep a good market balance."  

Employer Perspective (Purchasing healthcare benefits on behalf of their employees and dependents)

Per Modern Healthcare (9-5-02):  According to a Kaiser Family Foundation survey employers' health insurance premiums increased 12.7% in 2002, the sharpest rise since 1990, according to a Kaiser 

According to the Chicago Tribune (10/23/01) "Business Coalition Copes with Health-Care Cost Pressures", the Chicago Business Group on Health which used a joint purchasing initiative to buy health insurance next year for 13 Chicago are employers from local HMOs claims that they have 67,000 insured employees form 13 employers which pay more than $110 million in annual premiums and that the participating employers kept their rate increases to an average of 12.6% for 2002 and that had the employers bought insurance from the HMOs on their own the rate increases would have ranged between 18 and 35%.

Patient Perspective (Employee obtaining health insurance coverage)

11/6/01:  According to an article in the Chicago Tribune (11/6/01), "Employees Receive a Dose of Reality" with subtitle "Cost of Health Care is Rising", after being restrained for several years by managed care, health care costs are going to be rising in double digits for a number of years.  This article indicates that in 1999 about half of the companies surveyed by William M. Mercer Inc, a consulting firm, planned to shift additional health-care costs to employees and this year it found that two-thirds plan to do so and they are finding an average increase of 18% in overall health care costs for private sector employers.  Another benefits consulting firm claims that a key factor is the 15 to 20% nationwide increase in the cost of prescription drug coverage. As employers have more difficulty absorbing the increasing costs, they are being forced to pass on more of the costs to workers and the increases cans be in the form of increased premiums as well as increases in co-payments (the share of a medical bill that the worker must pay), deductibles (the amount workers must pay before insurance is triggered) or coinsurance (instead of a flat co-payment, the company would pay 80% of the cost of a prescription for example and the worker pay 20%).  This article looks at what can the worker do and suggests that the worker:  

According to the New York Times on 2-14-02, "Personal Costs for Medicare H.M.O.'s Rise":  "Elderly and disabled members of Medicare H.M.O.'s used nearly 50 percent more of their own money on average for medical care in 2001 than they did three years ago, health care researchers said yesterday... Out-of-pocket costs rose 62 percent to $3,578 in 2001 for people in poor health as their share of spending rose for prescription drugs, premiums and other services not fully covered by Medicare. Personal spending rose 43 percent to $1,195 from 1999 to 2001 for those in good health."

Provider Perspective:    Recourse for delayed or Denied Payment for Services Provided

 According to the Chicago Tribune ((January 16, 2001), section 3, page 2:  "A network of physicians, Unified Physicians Network Inc, has sued Chicago's second largest managed care plan, United HealthCare of Illinois, over various payment issues, alleging that United failed to pay more than $550,000 owed to the doctor's group.  This comes less than four months after Rush Presbyterian St Luke's Medical Center and four affiliate hospitals terminated a contract with United HealthCare of Illinois.  

According to Sarah A. Klein's article in Crain's Chicago Business, "Physician Finds Own Rx for Insurer Ills," with sub-caption "Suit for Payment Part of Activist Trend by Doctors" (January 15, 2001):  A Chicago ear, nose throat physician, Dr. John T. McMahan, sued an insurer, Employers Health Insurance Co,, a subsidiary of Humana Inc., for delaying or denying payment for services he provided.  The case settled for $145,000 covering all of the alleged underpayments and attorneys' fees.

    The American Medical Association, according to this article, assisted 31 state medical societies in surveying physicians to help determine the severity of this problem and found that this is a big issue and that some of the plans were taking 120 to 180 days to pay.

    According to a Humana spokeswoman in this article, in some cases, delays occur because physicians submit incomplete forms for payment.  Dr. McMahon, according to his attorneys, did not have that problem because he billed for a limited number of services and used a sophisticated computer system that allowed him to closely monitor the speed and size of reimbursements.  

   Per this article, many doctors, especially internists who bill for hundreds of different billing codes who have difficulty tracking a pattern, or get worn down by the bureaucratic process of insurers to challenge alleged underpayments end up settling for a fraction of the amount that they are owed. 

According to Chicago Tribune (August 16, 2001), "Dentists' Group Sues Aetna on Payments for Service," dentists are joining physicians in filing lawsuits against managed care plans.  The American Dental Association filed a lawsuit in Chicago against Aetna Inc., the nation's largest managed care plan, claiming that the insurer uses faulty data to reduce payments to thousands of dentist.

September, 2000:    Hospital Care Key Cost Driver in 2000 per Center for Studying Health System Change.

3-2-02:  According to Crain's Chicago Business:  "Frankfort-based health care system Provena Health plans to withdraw from Vista Health, a joint venture with Victory Health Services that combined the operations of two Waukegan hospitals, Provena St. Therese Medical Center and Victory Memorial Hospital.  Insurers alleged that the venture violated anti-trust laws by raising the rates it charged insurers before the hospitals fully consolidated their operations (Crain's, Jan. 29, 2001).  A spokesman confirmed that Provena St. Therese will remain with the joint venture, and Provena Health will not receive any compensation for the hospital."

According to "2 Hospitals to Merge in Waukegan," Chicago Tribune, (September 9, 2000):  110 year old Victory Memorial Hospital and Provena St. Therese Medical Center in Waukegan, IL will consolidate into one one facility due to dwindling revenue caused by managed care and reductions in federal Medicare spending.  The new health system will be known as Vista Health. Victory Memorial will eventually close.  Deal is expected to take two to three years to complete as each hospital board must sign off, various regulatory requirements, and certain upgrades are necessary for Provena to accommodate additional emergency and obstetric patients. Both facilities are suffering from empty hospital beds, "like most other acute-care facilities, in that managed care and trends in science are keeping patients out of hospitals and in less costly outpatient care settings."  President of Victory Memorial says, "It doesn't make sense to have hospitals three or so miles away offering the same services up and down the line, with both facilities operating half empty."  Both hospitals were operating at less than 55% capacity.  Chairman of the board of Vista Health said:   "Not all that long ago, a patient would spend almost a week in the hospital for gall bladder surgery.  Now it is often outpatient surgery.  When my wife had our babies, she stayed for a week; my daughter was home in two days."  Since Provena is a Catholic hospital merging with a non-Catholic Victory Memorial, sterilization services will eventually end at Victory Memorial but may be provided at a Victory-affiliated outpatient surgery center that would be operated separately.

Unions

5-9-02:  The American Medical Association has refused to continue financial support of the union it helped form in 1999, the Physicians for Responsible Negotiation.  PRN President Susan Adelman, M.D., who also is on the AMA’s board, resigned in response to the board’s April 18 decision.  (Source: Modern Healthcare)

From Chicago Tribune (2-5-02) Section 3, page3, "Doctors' Union Gets Some Life Support From Labor Board," indicates that the National Labor Relations Board said about 20 physicians employed by Occupational Health Centers of New Jersey are employees, not supervisors, and should be allowed to collectively bargain.  This ruling should help the American Medical Association (AMA) union, Physicians for Responsible Negotiation (PRN) which had a major setback last year when the U.S. Supreme Court held in a Kentucky case that nurses and other health care workers were excluded from bargaining if their duties included supervising others which the AMA interpresteds to mean that this ruling made it more difficult for employed physicians in the private sector to bargain collectively.  The AMA's PRN's top executives resigned, and the union had trouble attracting members.  This NLRB ruling indicates according to PRN that the NLRB "concluded that our physicians in fact only directed the manner in which other employees performed discrete tasks, but they do not supervise those employees."  Concentra Inc., a Dallas company, the parent of Occupational Health Centers plans to appeal the NLRB's ruling. The AMA formed the PRN union in "1999 amid widespread physician complaints that the managed care system shifted medical decision-making to insurance administrators from health care professionals.  

    According to April 3, 2001, Chicago Tribune, "Residents, Interns at Sinai Create Staff Group," about 160 residents and interns at Sinai Health System (parent of Mt. Sinai Hospital and Schwab Rehabilitation Hospital on Chicago's west side) have formed a house staff organization for input on hospital operations and medical training.  This group has not formed a union at this point in hopes that the hospital management will recognize their concerns by having a "formal protocol" for discussing issues.  Siani residents say this is not about money and the chief general surgery resident is quoted as saying that "we want to be able to advocate for improvements in patient care."  

A November 1999 ruling by the National Labor Relations Board allowed residents and interns who work at private hospitals to unionize.  Last year about 800 residents at Northwestern Memorial Hospital and four affiliated health facilities formed a house staff organization that helped win expanded health benefits and perks.  Also, 170 residents at Advocate Lutheran General Hospital in Park Ridge, Illinois are in final stages to unionize pending an appeal of an NLRB ruling on the eligibility of certain residents to vote in the election.

From HHS press Release 2/22/02:  With new evidence of a growing shortage of nurses, HHS Secretary Tommy G. Thompson and Education Secretary Rod Paige today launched a campaign to encourage school children to consider careers in nursing and the health professions.  The 2000 National Sample Survey of Registered Nurses report released by Secretary Thompson shows that the age of nurses increasing and rate of nurses entering profession decreasing.  The "Kids into Health Careers" tool kit has information on more than 270 health careers, such as nurse, physical therapist, x-ray technician, sports therapist and emergency medical technician is available.  The survey, conducted every four years by Health Resources and Services Administration (HRSA), also found that: the U.S. population increased by nearly 14 percent between 1990 and 2000, but the rate of nurses entering the workforce between 1996 and 2000 was just 4.1 percent, down from more than 14 percent between 1992 and 1996; there are an estimated 2,696,540 active, licensed RNs in the United States, an increase of only 137,666 nurses from 1996; 81.7 percent or 2,115,815 of active licensed RNs are employed in nursing; 12.3 percent or 333,368 of all RNs reported being from one or more racial or ethnic minority backgrounds; 5.9 percent of RNs employed in nursing are men, up from 5.4 percent in 1996; and the number of nurses working in hospitals increased slightly from 1,270,870 in 1996 to 1,300,323 in 2000.  President Bush's fiscal year 2003 budget proposes a total of $15 million, nearly a 50 percent increase above last year's funding, to expand the Nursing Education Loan Repayment program to help address the nation's growing need for nursing professionals. 

The Rush System for Health terminated its contract with Aetna Inc. effective March 8, 2002 after four months of unsuccessful contract negotiations, according to Crain's Chicago Business (11-26-01) page 2.

Pay cuts (2.5 -6.3%) for managers and their staffs and reducing about 35 full-time equivalent employee (FTE) at Mercy Hospital and Medical Center is part of the financial turnaround plan, sparing nurses and medical technicians and other healthcare workers involved in day-to-day patient care. Per Chicago Tribune (2-5-02), section 3, page 3.

Consider for Medical Records

10/8/01:    According to the American Health Information Management Association's
("AHIMA") advances in medical records technologies and the
patient's expanded role in compiling health records requires that
organizations reassess how they define a legal medical record.  AHIMA's latest Practice Brief provides healthcare organizations with guidance on crafting a viable definition of a legal medical record.  While acknowledging that variations in state laws and regulations preclude a "one-size-fits-all" definition, AHIMA said its "Guidelines for Defining the Health Record for Legal Purposes" offers a set of "common principles" for healthcare organizations to follow in establishing their definitions. The Guidelines divide the health record into four categories: legal health
record, patient-identifiable source data, administrative data, and derived data.

To read the AHIMA's new Guidelines, see:
http://www.ahima.org/journal/practice.brief.html and select "Guidelines for Defining the Health Record for Legal Purposes"

"Report Shows Families Better Off Under Welfare Reform"

According to HHS press release 8/21/01:  "Enacted by Congress and signed into law in August 1996, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 dramatically changed the nation's welfare system into one that requires work in exchange for time-limited assistance. The act contains strong work requirements combined with supports for families moving from welfare to work, including increased funding for child care and continued eligibility for medical coverage.  Since August 1996, the welfare caseload has fallen from 12.2 million recipients to 5.8 million - the largest decline in history and the lowest percentage of the population on welfare since 1965."

"HHS Announces $24.8 Million in Grants" 

According to HHS press release 8/17/0: President Bush's five-year plan includes to add 1,200 new health center sites and to double the number of people who are served by community health centers.  according to this press release, "Today's Service Expansion grants will enable health centers in 46 states and Puerto Rico to offer patients new or expanded oral health, pharmacy, mental health and substance abuse services at current sites. The funds also will allow grantees to strengthen community outreach and increase primary care
services provided through the Health Care for the Homeless program. The
grants overall will broaden access for about 200,000 people...Through extensive partnerships with local providers, hospitals and managed care organizations, health
centers build local systems of care that increase residents' access to
health services...President Bush has asked Congress for $1.3 billion to support HHS'
Consolidated Health Centers program in fiscal year 2002 -- $124 million more
than in this year's appropriation."

Charity Care Dropping

The proportion of physicians providing charity care dropped from 76 percent to 72 percent between 1997 and 1999, raising concerns that access to care for poor and uninsured people could decline in the future, according to a study released today by the Center for Studying Health System Change (HSC).  While the overall number of practicing patient care physicians increased slightly from 347,000 in 1997 to 363,000 in 1999, the number of physicians providing charity care -- about 260,000 -- remained constant, meaning the proportion of physicians providing charity care declined, according to the study. (8/23/0)

Blue Cross Backs away from Deal

According to Chicago Tribune (August 16, 2001), "Blue Cross Cancels Deal with Regence" with subtitle "Affiliation would have built clout" states that Blue Cross and Blue Shield of Illinois, a not-for-profit mutual insurer owned by policyholders, has merged with or acquired other entities and now has nearly 7 million members.  The affiliation with Regence, which has 4 million customers has a different culture than Blue Cross and Blue Shield because Regents plans are linked with each other largely through shared management and the assets of those plans are separate while the plans are owned by either policyholders or nonprofit corporations.  Regence serves primarily regional employers in the Northwest while the Illinois Blues has a large business with national employer accounts.  Both plans appear to have decided to back away from the deal.  Blue Cross and Blue Shield of Illinois intends to grow without converting to a publicly traded firm and will seek deals with Blues plans in other parts of the country.

HMOs Exiting Medicare Market

According to Crain's Chicago Business (July 9, 2001), "A Critical Condition for HMOs" subtitle "As Medicare Rate Deadline Nears, Two Insurers Show Symptoms of Stress," the combination of increases in the cost of physician and hospital services with nearly flat federal reimbursements have squeezed profits to the point that the last two remaining players in the Illinois Medicare HMO Market, Humana and United Healthcare of Illinois, are likely to exit the Medicare market and leave 103,000 Cook county seniors with fewer and costlier options.  Federal reimbursement appears to be 2% increases and industry observers say the federal government would have to boost reimbursement rates by about 5% to 6% for Humana and UnitedHealthcare to stay in the game.  Humana's first-quarter 10Q filing reports earnings of $30 million on revenues of $1.10 billion for its Medicare+Choice, Medicaid and military health insurance products.  Nationwide, Humana spent 85% of every dollar of premium revenue on medical expenses.  UnitedHealth Group in Minnesota whiche owns UnitedHealthcare of Illinois reports similar medical costs in public filings.  

Approach to Patient Rights

According to Crain's Chicago Business (July 9, 2001) the American Medical Association terminated its membership in the U.S. Chamber of Commerce because the "two organizations disagree on patients' rights".

Illinois State Medical Society 

According to the Chicago Tribune June 19, 2001, "State Medical Society Works to Heal Membership Losses" by Bruce Japsen, the Illinois State Medical Society membership dropped nearly 30% to less than 10,000 from 13,733 dues-paying physicians translating into a loss of about $1.7 million in dues revenue over that four year period.  The medical society's leadership is confident that physicians are coming back now with the various new programs the medical society has implemented.  Last year the medical society launched a division of membership and advocacy to help physicians deal with insurance companies or complex regulations involving Medicare or Medicaid.  Also, charging less dues for younger physicians and ending the requirement that to belong to the medical society physicians also had to belong to the American Medical Society (AMA) has helped attract more physicians to join the medical society.

5/15/01:  Tobacco Settlement Funds For Middle Income Seniors

Acting New Jersey Gov. Donald T. DiFrancesco signed a bill to create a $60 million prescription drug benefit plan for moderate-income senior and disabled New Jersey residents. The state's share of the national tobacco settlement will fund this plan.  Approximately 100,000 state seniors and disabled persons will be eligible to participate in the Senior Gold Prescription Drug Discount Program beginning on June 1. Participants will be responsible for a $15 co-pay while the state will pay 50% of the remaining cost. For individuals whose out-of-pocket drug costs exceed $2,000 and for couples whose costs exceed $3,000, the state will pay the entire cost after the co-payment. Participants will be able to use the pharmacy of their choice. The state already provides prescription drug benefits to low-income seniors under a separate program.  See governor's press release about the plan at:  
http://www.state.nj.us/governor/news/p10516a.html.
See the law at:  http://www.njleg.state.nj.us/html/bill2000.htm
and search by Bill Number for S6.

Re:    ERISA

Cases where ERISA preemption is not upheld:

Pennsylvania court rules that ERISA does not exempt health plans from liability
<http://www.ama-assn.org/sci-pubs/amnews/pick_01/gvsa0507.htm>

The Pennsylvania Supreme Court held in the case Pappas v. Asbel, No. J-158-2000 (Pa. Apr. 3, 2001) ("Pappas II"), that the Employee Retirement Income Security Act ("ERISA") does not pre-empt a state law claim asserting that a health maintenance organization ("HMO") was negligent in providing medical benefits to a plan member when it refused to authorize coverage at a non-HMO hospital recommended by the attending physician.  Pappas was admitted to a hospital's emergency room for treatment and was delayed in being transferred to a facility adequately equipped and immediately available to handle his neurological emergency while his physicians contacted the HMO to get transfer authorization; he was eventually admitted to an HMO-affiliated hospital. Pappas sued the first hospital and its physicians for negligence and malpractice, alleging that the delay in transfer caused his permanent paralysis. Defendants filed third-party complaints against the HMO for refusing to authorize the transfer to the facility selected by the medical staff. The Pennsylvania
Supreme Court initially ruled ERISA did not pre-empt the third party claims.
However, the U.S. Supreme Court vacated and remanded the decision for
reconsideration in light of Pegram v. Herdrich, 120 S. Ct. 2143 (2000), in
which the Court held that treatment decisions made by an HMO, acting through
its physicians, are not fiduciary acts within the meaning of ERISA. On
remand, the Pennsylvania Supreme Court concluded that plaintiff's circumstances triggered a mixed eligibility and treatment decision that would be appropriately addressed through state medical malpractice law and affirmed its previous decision, again holding that the claims against the HMO were not pre-empted. A dissenting justice would have allowed the HMO to assert pre-emption arguments, citing other case law, including the Third Circuit's recent decision in Pryzbowski (see below).

See the Pennsylvania courts' opinions page at:  
http://www.courts.state.pa.us/Index/Opinions/IndexOpinions.asp.

Cases where ERISA preemption is upheld:

In the case Pryzbowksi v. U.S. Healthcare, Inc., No. 99-5920 (3d Cir. Mar. 27, 2001) an HMO member suffered injury due to the plan's negligent delay in
approving care by out-of-network physicians.  The appeals panel found that the participant's claims for delay in approval of her care involved the plan
administration, not the quality of the care she received and, thus, ERISA
pre-empted those claims. However, the panel remanded the issue of whether
plaintiff could assert state law claims against her primary care doctor and
attending physicians for the delay. It also ruled that there was no New
Jersey state law duty for a physician to advocate on the patient's behalf
when a health plan denies the treatment the physician recommended.

See case at:  http://vls.law.vill.edu/locator/3d/Mar2001/995920.txt

HMO liability

In federal district court in Miami, an amended complaint was filed on March 27, 2001 adding the Texas Medical Association and the Georgia Medical Association along with individual physicians in various states, as plaintiffs in a suit filed last year by the California Medical Association (CMA) alleging that certain health plans violated federal racketeering laws by enriching themselves at doctors' and patients' expense, broke their contracts with doctors, and jeopardized patient welfare.  Plaintiffs allege that defendants engaged in a common scheme to deny, delay, and diminish payments to physicians.  Plaintiffs seek injunctive relief and monetary damages.  Defendants include:  Blue Cross/ Wellpoint, Foundation Health Net, Pacificare, Humana, Cigna, Aetna and its Prudential unit, United Healthcare, and Coventry Health Care.  See:  In re Humana Inc Managed Care Litigation, MDL No. 1344 (S. D. Fla. filed March 27, 2001); California Medical Association website at:  http://www.cmanet.org; Texas Medical Association website at:  http://texmed.org

Re: Medicaid Managed Care

April 19, 2001: HHS announced the renewal of a program in Pennsylvania that helps Medicaid beneficiaries gain access to needed medical services.  The 1915(b) waiver program in that state uses a primary care case management (PCCM) system in which Medicaid enrollees have all of their health care services coordinated by one physician. The PCCM process allows greater access to preventative as well as ongoing care that, the state reports, has lowered the inappropriate use of expensive emergency room visits.  Thompson said:  "Using case managers to assure continuity of care puts those with low incomes on a level playing field when it comes to access to proper healthcare.  It allows health conditions to be treated before they become emergencies and people end up much sicker and in an expensive emergency room. setting." This program serves 8000 enrollees which surveys show are pleased and is said to have saved nearly $6 million over what Medicaid for this group would have cost in the absence of the waiver.

April 18, 2001: HHS Secretary Tommy G. Thompson announced approval of Colorado's request to continue for two more years a state program to provide mental health services for Medicaid beneficiaries through managed care.  o further assure the quality of care provided under the managed care plan, the approval today is contingent on the state taking an even more active role in monitoring the program. For instance, the agreement calls for the state to conduct consumer satisfaction surveys, develop a timeline to analyze and monitor complaints, grievances and appeals, and be more active in monitoring services for children with special needs.

HCFA is the nation's largest health insurer, providing insurance coverage
for more than 74 million Americans through Medicare and, in partnership with
states, Medicaid and the State Children's Health Insurance Program. In
addition, HCFA oversees nursing homes, hospitals and other health care
entities.

According to AMNews, May 7, 2001: Some physicians do not like to be called "provider". 

April 20, 2001:  Health Resources and Services Administration (HRSA), will provide nearly $105,000 to pilot programs to boost cardiac survival rates in rural areas, HHS
Secretary Tommy G. Thompson announced today. Overall, HRSA will be
administering approximately $300,000 to support rural Emergency Medical
Services activities.  he demonstrations will explore ways of establishing community partnerships to buy and maintain automated external defibrillators (AEDs) and to train personnel in using them. AEDs allow trained, non-professional rescuers to
shock the heart of cardiac arrest victims back into normal rhythm. Speed is
crucial in responding to cardiac arrest, since a victim's chance of survival
drops 10 percent for every minute that passes before the heart is returned
to a normal rhythm.

April 23, 2001: HHS announced new Patient Safety Task Force within HHS that will coordinate a joint effort among several department agencies to improve existing systems to collect data on patient safety. The federal agencies leading this effort include the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the Health Care Financing Administration (HCFA).  Secretary Thompson has charged
the Task Force with studying how to implement a user-friendly Internet-based
patient safety reporting format. HHS' fiscal year 2002 budget proposal includes up $72 million, an increase of $15 million over fiscal year 2001, for efforts to improve patient safety and reduce adverse events.

April 25, 2001: To ensure that science-based information about cardiovascular disease (CVD) reaches people in low-income and minority communities, the National Heart, Lung, and Blood Institute (NHLBI) at the National Institutes of
Health today announced a partnership with six community- based organizations. These organizations, which have been dubbed Enhanced Dissemination and Utilization Centers (EDUCs), are the first to be selected to participate in
what will eventually be a nationwide NHLBI network of community-based organizations implementing targeted, culturally sensitive heart health education strategies aimed at changing local physician practices and patient
behaviors.

For more information, contact the NHLBI Communications
Office, at (301) 496-4236. For additional information on the NHLBI CVD EDUCs and
cardiovascular health, visit the NHLBI Web Site at
www.nhlbi.nih.gov.

Centers for Excellence

"Hospital Defends Psych Changes," with subtitle "Highland Park Facility Latest to Close a Unit that Served Adults" per Chicago Tribune (March 16, 2001), there is concern about the decrease in acute mental health care for adults in Lake County in the last 18 months.  According to Evanston Northwestern Healthcare officials, the plan is part of an "effort to establish a comprehensive 'center for excellence' in both outpatient and in-care psychiatric treatment for adolescents."  More hospitals across the nation are developing "centers for excellence" modeled after the Mayo Clinic approach.  This article explores the reaction to Highland Park Hospital's plan to "change its psychiatric inpatient unit to a service for adolescents" in conjunction with the announcement this year by Condell Medical Center in Libertyville to close 20 mental health care beds and the closure of 10 to 20 adult psychiatric beds by Victory Memorial Hospital in Waukegan after its merger with another hospital.  Two Highland Park psychiatrists referred to in the article are opposed to the closing of Highland Park to adult patients because:  at least four patients refused to transfer to a different hospital, one patient was insured for Highland Park Hospital but not Evanston and had to be transferred to a different hospital, and that the community "needs more than a Mayo Clinic," that "It needs a hospital that provides everyday (psychiatric) care."

According to Crain's Chicago Business (March 12, 2001):  "AMA Dues Revenues Turn Anemic", membership in the American Medical Association went down 1% last year, down 3,338 members from 1999 with yearend membership at 290,357.  Medical students gained in membership though at reduced membership rates.  Dues contributing to about 25% of the group's budget have been dropping since 1997 with due revenues for 2000 expected to show a decline of $4million or 6% to $57.9 million.  An AMA advisory committee is considering new membership models including one to confer AMA membership on nay member of a related state medical group or specialty society with a final report to be presented to the AMA House of Delegates in December.  Another article in this issue of Crain's, "Hospitals Take Step Closer to Merger" indicates that Resurrection Health Care signed a letter of intent to acquire Elizabeth's Hospital from Ancilla Systems Inc. of Hobart, Ind.  Earlier this month the corporate sponsor of St. Mary of Nazareth Hospital Center merged with Resurrection.  a spokesman for the Chicago based hospital system said there are no plans to merge St. Elizabeth's with St. Mary though the article indicates that observers say such a consolidation is inevitable.

JCAHO News

3/19/01:    The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced March 15, 2001 that a medical surgery center practice in Salinas, California was the first office-based surgery practice to be accredited by the JCAHO. The president of JCAHO, Dennis S. O'Leary, M.D. said "Increasingly, complex and high-risk procedures are being performed in doctors' offices and freestanding surgery centers.  The new office-based surgery accreditation program demonstrates JCAHOs commitment to promoting patient safety and high quality services that meet the ever-evolving needs of health care organizations, practitioners and patients."

Wonder what happened with hospital mergers?  

According to an article in the New York Times (March 14, 2001), "Hospital Mergers Stumbling as Marriages of Conveience," by Jennifer Steinhauer, promises of financial gains have been largely unrealized and few clinical programs came together.  Many of the hospitals kept their own name so patients may not have even realized the hospitals merged.  Some money was saved by functions such as merging laundry services and legal departments.  Managed care contracts became more equitable but combining major clinical programs and blending cultures did not occur.  Also, there are sinals that some of the hospitals are growing apart.  As one person in the article is quoted as saying:  If you merge two hospitals, you have a large number of prima donnas who are used to taking orders from no one.  While having all of certain procedures in one place might mean higher quality, each hospital still tends to remain a cost and profit center and are not willing to give things up."

"Harmony HMO Likes Sound of Medicaid" 

Per Chicago Tribune ((January 30, 2001),section 3, page 2, only about 10 % of Illinois 1.4 million Medicaid recipients are now enrolled in an HMO.  This article states that "With such a small pool of Medicaid recipients to draw from, smaller plans left the program or merged with larger players because they were not getting enough subscribers to pay medical care costs and expand their business."  Now, Harmony is one of six Medicaid managed care plans in Illinois compared with 16 five years ago.  In Illinois, Medicaid plans market to individuals, but in Indiana Medicaid managed care patients must sign up for an HMO through their physician. Harmony is currently negotiating contracts with 100 northwest Indiana physicians who provide medical care to 80% of the estimated 50,000 Medicaid recipients in Lake County, Indiana. 

1/5th Medicare Population In Managed Care Plan

According to the Agency for Healthcare Research and Quality (AHRQ), (November, 2000):  Nearly one-fifth of the Medicare population is in a managed-care plan.  Studies have found that patients with managed care plans received fewer procedures than their fee-for-service counterparts. A recently published study found that Medicare patients enrolled in managed care plans are significantly less likely than those with traditional Medicare fee-for-service coverage to receive needed coronary angiography - a potentially lifesaving diagnostic procedure - following a heart attack, even though the procedure is a highly recommended practice.  

According to the Agency for Healthcare Research and Quality (AHRQ), (November, 2000), "Physicians Can be More Responsive to Patient's Concerns Without Lengthening Visits":  According to a study of patient clues and physician responses in primary care and surgical settings, physicians often miss opportunities to adequately acknowledge patients' feelings.  Patients typically provide two to three emotional clues to their doctors regarding anxiety about their medical condition or psychological or social concerns during a medical or surgical visit.  Many studies suggest that outcomes are better when doctors address patients' emotional concerns as well as their medical problems.   

According to the Agency for Healthcare Research and Quality (AHRQ), (November, 2000), " Organizational Factors Beyond the Control of Primary Care Physicians May Affect Patient Satisfaction Ratings,":  Because patient satisfaction with an office visit often hinges on more than the quality of the physician's direct care, such as organizational factors like waiting time, courtesy of non-physician staff.  Two organizational variables, waiting time to see the doctor and courtesy of non-physician office staff, explained 20% of the variance in patient responses to the four questions used to evaluate the quality of physician's care:  time spent with the doctor, information provided by the doctor, technical skills and personal manner.

According to the Chicago Tribune ((January 25, 2001):  "Drug Coverage Critical for Seniors," with sub-caption "3,000 Leave One Medicare HMO After Benefit Cut,).  According to this article, United HealthCare of Illinois lost nearly 7% of its Medicare HMO business since October when it said it would eliminate drug coverage in Cook County effective January 1.  According to analysts, about 15% of the nation's 39 million Medicare beneficiaries are enrolled in Medicare HMOs largely because of drug benefits.  Nearly 120,000 are enrolled in Medicare HMOs in Chicago area.

The U.S. Equal Employment Opportunity Commission (EEOC) issued a Commission Decision finding merit in two charges of discrimination alleging violations of Title VII of the Civil Rights Act of 1964, as amended by the Pregnancy Discrimination Act. according to a press release by the EEOC:  "The Commission based its decision on the grounds that the respondents in the charges excluded the cost of prescription contraceptive drugs - available only to women - from their employee health plan while covering a number of other preventive drugs, devices, and services. The plan also covers surgical sterilization for both men and women as well as Viagra.  The charging parties sought to use contraceptives both for birth control and other medical purposes.  The Commission concluded that the respondents' plan violates the Pregnancy Discrimination Act's prohibition against discrimination on the basis of pregnancy."  See:  http://www.eeoc.gov/press/12-13-00.html

EMPLOYER PERSPECTIVE:

According to a recent survey by 2000 Randstad North American Employee Review as reported in the Chicago Tribune on December 10, 2000:  70% reported that health insurance/ benefits would make an employee decide to stay in current job if another job were offered as compared to 59% for competitive wages, 45% outside training resources, 37% bonuses based on company profits and 37% tuition reimbursement.

RESIDENT'S UNION ISSUES:

"Hospital's Residents Get OK for Union Vote," sub-caption, "Lutheran General Doctors Win Ruling," Chicago Tribune ((November 10, 2000), section 2, pages 1 and 2:  According to this article, nearly 180 residents at Lutheran General Hospital in Park Ridge, Illinois may hold an election on whether to form a union.  The residents are the first in the country to petition for an election since the National Labor Relations Board (NLRB) ruling in November 1999 that changed the long held status of residents being students and not employees and therefore ineligible to bargain collectively.  The November 1999 ruling allowed residents at the nation's 5,000 private hospitals to organize.  An election is expected to be held within the next four weeks.  

The NLRB settled a 2-year old dispute brought by 430 medical professionals at Boston Medical Center ruling that interns and residents who work in private hospitals are employees and and have the option to join unions.  This vote overturned the 1976 decision holding that residents, interns and fellows at Cedars-Sinai Hospital in Los Angeles were students.  This article states that:  "Residents said they are upset that they had to pay health insurance premiums this year, costs that previously were paid by the hospital.  They also want better parking spaces, which were moved across the street from the hospital without input from the doctors."  The residents claimed they had a "house staff organization" but that it was not effective.  This article refers to the "more than 800 residents at Northwestern Memorial Hospital and five affiliated health facilities" that recently created a house staff.  The American Medical Association's (AMA) Physicians for Responsible Negotiation (PRN) said they would represent Lutheran General residents.  The PRN was created by the AMA last year to held doctors with working conditions and negotiate with insurance companies.  

"Hospital Seeking a Union Antidote," sub-caption "As Residents Organize, Northwestern Fights Back,"  According to this article By Sarah A. Klein, Crain's Chicago Business (October 30, 2000):  residents at Northwestern Memorial Hospital concerned about low pay, inadequate health insurance, disorganized and unresponsive administration formed McGaw House Officers Alliance.  This alliance was formed to improve working conditions and voice concerns about patient care issues.  This alliance gained bargaining rights from the National Labor Relations Board last November and according to organized labor groups the medical center is on probation with an accreditation agency for allegedly overworking its general surgery residents.  Prior to the group's formation residents starting salaries was well below the national average.  Since its formation, the medical center offered residents a 5.1% raise, expanded health coverage, and increased number of parking spots for residents working downtown.  Northwestern Memorial Hospital and its teaching affiliates have formed their own association to "act as in-house advocate for doctors in residence".  

INSURER/ MCO PERSPECTIVES:

On December 12, the Health Insurance Association of America ("HIAA") announced that it was no longer discussing the possibility of merger with the American
Association of Health Plans ("AAHP").  A press release from HIAA indicated that the two organizations will remain separate.  Prior to this time, various sources reported that HIAA and AAHP had agreed in principle to merge.  The two groups have a combined budget of nearly $45 million and employ about 200 people. Both have been heavily involved in the fight on Capitol Hill over prescription drugs and patients' rights.  The AAHP has a budget of nearly $25 million, represents hundreds of managed-care plans, while the HIAA represents private insurance companies, including Cigna and Aetna.

 MEDICARE HMOs - DRUG BENEFITS

"HMOs Cut More Seniors' Drug Benefits," with sub-caption "45,000 More in Cook Lose Prescription," Chicago Tribune (November 7, 2000):  Section 1, page 1 and 13.

About 6 million seniors are covered by Medicare HMOs and about half of them will see their drug benefits cut next year according to the Health Care Financing Administration which runs the federal Medicare health insurance program for the elderly and disabled.  

According to this article, in June many HMOs covering nearly 1 million seniors said they would drop out of the Medicare's managed care program because they contend government payments are not keeping up with the rising drug costs.

Two outside union organizations referred to in the article are:  (1)  American Medical Association's Physicians for Responsible Negotiations in Chicago and (2) New York based Committee on Interns and Residents which affiliated with the Service Employees International Union.

According to Crain's Chicago Business (November 6, 2000), Unicare health plans in Chicago is "pulling out of the Medicare HMO program, leaving about 3,500 area seniors without prescription drug coverage and other benefits."

10/26/00  "High-Tech Bypass for a Clogged health-Care System" with sub-heading "Internet Links to Insurers Help Doctors Speed Up Referrals, Streamline Office Processes," by Rhonda L. Rundle, The Wall Street Journal (October 23, 2000), pages B1 and B6:

This article indicates that there is hope in the future with E-Health Internet technology to help doctors with their administrative burdens from dealing with managed care companies.  For some doctors, the burdens are so bad, that they are seriously considering quitting the practice of medicine.

A particular doctor, feeling "angry and demoralized by the administrative burdens of his practice" who is rated on many regional "best doctor" lists and his medical group, PriMed LLC, has 14 offices and cares for more than 100,000 people called the CEO of PHS Health Plans, the largest managed care provider in Connecticut and told her of his feelings.  The managed care company's CEO immediately set up a meeting with the doctor and went to his office the next day to find that it was "over-stimulating" with little sticky notes with numbers and codes and rules posted everywhere and with walls lined with rows of printed forms.  The PriMed doctors agreed to test a software system that PHS was developing with NaviMedix, a technology company in Boston.  This software system streamlines routine tasks such as verifying patient's coverage and determining if a prescription drug is covered and how much the patient must pay.  PriMed's management company handles claims and billing.

According to one of the PriMed doctors where the software went live, the software system makes referrals to specialists so much easier and faster.  The procedure takes about one minute (about one-fifth of the time in using the old manual process and the member-eligibility function is cut to seven the number of PriMed claims that were rejected by PHS in one recent month, down from a monthly average of between 350 and 450), a member's name and diagnosis is typed on a computer, a list of specialists is accessed and you can click on one to whom the patient is being sent.  After hitting the send button, a quick message of approval is usually received.  This doctor is eager to test various online ventures such as prescription writing services that link doctors, health plans and pharmacies.  Limitations of the system include: cardiologists, oncologists and other specialists aren't online yet, and those patients who belong to other health plans, other than PHS (more than half), must be handled manually. 

"Still Ailing" with sub-heading "Using the Web to Create a Networked Health-care System is Still More a Dream Than Reality," by Ann Carrns,  The Wall Street Journal (October 23, 2000), page R40:

This is an article stating that consumers are well ahead of the healthcare establishment in embracing the Web.  This article state "universal use of an online medical record - a computerized compilation of a patient's medical history accessible to both doctors and patients - remains years away".  According to a survey by Cyber Dialogue, a New York Internet research firm, just 200,000 Americans have bought prescription drugs online and 3.7 million American adults say they have e-mailed their doctor's office while 33.6 million are interested in doing so.  MedicaLogic/ Medscape Inc., Hillsboro, Oregon, has marketed electronic medical -record software for more than ten years claims that it has 13.4 million patient records on its systems.  According to a survey by Medem Inc., a San Francisco Web services company financed by the American Medical Association and other professional groups 36% of doctors who do not have a Web site plan to establish one in the coming year.  This same survey found that 10% of doctors use e-mail with their patients regularly.

There is a rush of new Web companies such as HealthMarket Inc. to provide comparative medical price and quality information "at consumers fingertips, enabling patients to arrange for services at a prearranged price."  These type of sites are expected to become a trend as defined contribution plans, in which employers give workers a lump sum to arrange for their own health care services intensifies.  WebMD is still considered the Internet health front-runner despite all of its problems.  Martin Wygod, now the company's sole CEO stated back in February when predicting the company's plans to wire healthcare that "It's a huge undertaking.  It's going to take longer than everyone thinks.  But we will get there."

The eight million members of Kaiser Permanente of Oakland, California can go to www.kponline.org to make non-emergency appointments with their physicians or to seek advice from a nurse.  However there were some problems with this when some confidential e-mails were sent to Kaiser members who were not the intended recipients.  Though, the company says it has changed its procedures to prevent this from occurring again.

"Banks Checking Out Doctors' Biz," by Sarah A. Klein, Crain's Chicago Business (October 23, 2000), page 3 and 57, showing how dozens of  the 240 physicians at Advocate Medical Group are leaving Advocate because Advocate intends to cut their pay 10% to 30%, so they are setting up practices, need start-up loans, bank accounts and investment advice.

This article states that there is "industry speculation that there will be more practice separations as medical centers consolidate or shrink operations".  Banks so far doing this include:  Cole Taylor Bank, Citibank FSB, and Harris Bank.  Physicians are now seeing loan offers at or below prime rate, relatively low personal guarantee requirements on loans and interest-only repayment at the outset.  Banks like these physicians as clients because each physician brings in, on average, $300,000 to $400,000 a year in billings.  Banks may want to pay close attention to the billing staff in a physician's office, wanting an explanation of who is in charge and their experience and consider Medicare and Medicaid reimbursement issues, accounts receivables issues such as that they may flow in slowly form private third party insurers and individual patients, troubles with hospitals and HMOs.   

This article states that "offering a discount on commercial business to gain access to personal accounts is illegal", however this article quotes an attorney who states that banks can be very "competitive with their rates, hoping there will be ancillary services".  Things are different now as compared to 1998, when bankers were not knocking on physicians doors, as indicated by Dr. Antonio Barajas experience when  Louis A. Weiss Memorial Hospital in Chicago gave him two weeks notice that the hospital decided to close his satellite clinic and another downtown location.  Dr. Barajas had to scramble to find a new location and buy computers and telephone service and took out a $40,000 home equity loan to cover expenses.  

The Wall Street Journal (October 24, 2000), B14 reports HCA, of Nashville, Tennessee, formerly known as Columbia/ HCA, net income rose with signs of resurgence by hospitals.  This year, HCA agreed to pay a record $745 million as part of a civil judgment with the Justice Department.  Strong earning appear to be coming from:  working out better deals with managed care operators including as far as HMOS "giving up business if that were necessary, rather than agree to a hurtful deal".

According to the Chicago Tribune, October 24, 2000, section 3, page 2, Holy Cross Hospital is projecting a $7,5 million operating loss for 2001 with financial recovery at least two years out, despite efforts to reduce employees and negotiate better contracts with health insurers.

See University of Illinois advertisement in Crain's Chicago Business (October 23, 2000), page 16, regarding "Virtual reality goggles": the hottest fashion for surgeons-in-training.  This advertisement states:  "Using a virtual reality version of the human ear, University of Illinois at Chicago medicial students and residents can navigate the tiny bones and channels of the ear to learn its anatomy and function.  A cutting edge technology so impressive, it was demonstrated for members of Congress as an innovation in medical education.  And better education means better physicians.  Because at the University of Illinois, technology is not just for our students, it's for the people of Illinois." 

"Health-care Insurance Bills to Jump" according to an article by Bruce Japsen in the Chicago Tribune (October 22, 2000),:

Premiums are expected to rise 10-13% and take their "biggest jump in a decade".  Citing a study by Hewitt Associates to be released this week, most employers will pay at least $125 more in premiums next year or $4.81 per paycheck every two weeks.  According to Hewitt, employers are passing along $1 of every $4 of company health benefit costs.  Health care premiums on average will be up about 10% for PPOs and point-of-service (POS) plans, 12% for traditional indemnity plans and 13% for HMOs.

Smaller companies insurance rates will be well into the double digits because of their lack of ability to spread risk and costs with a smaller employee base.  To hold increases down in a tight labor market, employers are redesigning health care benefit plans such as increasing a $10 co-pay to $15 or increasing premiums slightly or using POS plans so that if employees go out of network they pay more.  

According to analysts, much of the cost increase is attributed to rising demand for prescription drugs.  There has been an onslaught of direct to consumer drug advertising on television by drug companies since federal regulations on such advertising were eased 3 years ago making it tougher to control prescription usage.  According to some human resource personnel, on average drug costs are going up 20 to 25%.  More employers are turning to the three-tiered co-payment plans which includes a $5 or $10 copayment for generic drugs, $10 to $20 for brand names in the health plans menu of preferred drugs known as a formulary, and $25 or more for other drugs approved by the Food and Drug Administration.  These copayments are basically telling employees that they have to have a financial responsibility.    

"HHS ANNOUNCES MEDICARE PREMIUM AND DEDUCTIBLE RATES FOR 2001".

According to a HCFA press release on October 18, 2000:  The Department of Health and Human Services (HHS) announced the 2001 rates for the Medicare Part A deductible and Part B monthly premium amounts paid by beneficiaries.  The Medicare Part B monthly premium that covers physician services, hospital outpatient care, durable medical equipment and other services outside hospitals will be $50 in 2001, an increase of $4.50 from this year.  Most of Medicare's 39 million beneficiaries opt for this voluntary coverage.  The Medicare Part A deductible for inpatient hospital care will be $792 in 2001, an increase of $16 from this year.  
    
For further information call:  1-800-MEDICARE (1-800-633-4227) or see:   www.medicare.gov on the Internet.

According to The New York Times, October 13, 2000, both Jim Clark, the billionaire Silicon Valley creator of Healtheon that merged with WebMD founded by Jeff Arnold, an Atlanta marketing executive to become WebMD. resigned and Martin J. Wygod, took full control as the surviving chief executive of the troubled company focusing on profits.  Martin Wygod said in an interview that WebMD has been losing more than $80 million every three months.  Jim Clark said in a written statement that he needs to turn his attention to three private companies that he is actively involved with.  One of these companies is DNA Sciences, which is trying to develop medical diagnostic tools and treatments using genetic screening.

According to the article:  "Martin Wygod said he intended to integrate the company's Envoy unit, a widely used electronic system for sending and paying medical bills, and WebMd's Medical Manager software, which helps doctors organize their offices. He said his goal was to give doctors instant information about the insurance status of patients (and later their medical histories) on a hand-held computer."

"WebMD also plans to offer a conduit for transactions between insurance companies and other payers on one hand, and doctors, hospitals and health-plan members on the other. WebMD would provide behind-the- scenes software links for World Wide Web sites sponsored by the companies and providers. It would collect a small fee on each transaction."

"The competition includes big insurers who are creating their own proprietary systems and Medunite, a coalition of six large health-care companies that is trying to create similar electronic links. Mr. Wygod said WebMD could offer savings to payers and providers, building on its existing services."  "Most hospitals have switched to electronic networks to handle their billing, but most physicians' offices still depend on paper forms," Dr. Hochstadt, a San Francisco analyst said.

In a bid to attract and reta