Ten Keys to A Successful Ethics Program
1.Ensure top management support and involvement.
2.Use all available communication tools regularly to make sure training reaches every employee.
3.Carefully plan and execute an extensive internal audit program.
4.Design a risk-area assessment tool that will locate potential trouble spots.
5.Produce an easy-to-understand code of conduct and distribute it to all employees.
6.Design more detailed policies, procedures, and compliance aids for more complicated subjects.
7.Put in place an easy-to-use internal reporting mechanism.
8.Carry out unequivocal and consistent discipline for violations.
9.Make attention to compliance and ethics an important consideration in management promotions and evaluations.
10.Continually evaluate: access all failures, problems, and corrective actions.

Christy F. Batts, VP, Ethics and Business Conduct, Quorum Health Group, Inc., Brentwood, Tenn.

Top Ten Trends For Managed Care: 1997-2000
Noted healthcare futurist Russell C. Coile, Jr., made the following observations about the future of managed care:

-- Growth. Despite rising public criticism, managed care enrollment has continued to grow. In 1996, Medicare HMOs grew nearly 36% and Medicaid managed care membership rose by 58%. In some markets, however, HMO enrollment has peaked or even declined. In markets like Boston, Cleveland, and Los Angeles, HMO membership enrollment dropped by 3% to 5% in 1996.
-- Profits. HMOs have decided to sacrifice growth for higher profits by raising premiums. Price hikes that are too high, however, could create openings for provider-sponsored HMOs and direct contractors.
-- Market penetration. HMO enrollment has reached more than 50% in 10 major U.S. cities.
-- Consolidation. More than 45% of the nation's HMO members are enrolled in the 10 largest plans.
-- Concentration. In large metropolitan areas, the leading plan typically holds a 38% market share, with 21% held by the second largest plan. The third largest plan holds 12%, leaving only 29% of the market available for the smaller players.
-- Competition. The more than 500 regional provider-sponsored networks are boosting competition and positioning physicians and hospitals to potentially control the premium dollar.
-- Consumer backlash. HMOs, once the beneficiaries of protective legislation, are no longer seen as underdogs. Growing criticism of managed care is leading to inevitable regulatory reform efforts.
-- Gatekeepers. HMOs are responding to consumer demand for enhanced access to specialists by shifting away from the primary care gatekeeper model toward the use of "access managers."
-- Population management. Payment for healthcare services will become population-based and providers will become accountable for the health of defined populations.
-- Public health. Managed care is paying more attention to underlying public health conditions that can influence health risks and costs.

JCAHO Posts Healthcare Indicators
The Joint Commission on Accreditation of Healthcare Organizations has posted the National Library of Healthcare Indicators Health Plan and Network Edition (NLHI) on the Internet. NLH, the nation's first comprehensive compendium of validated performance measures for health plans and networks, can be found at http://www.jcaho.org/perfmeas/nlhi/nlhi_frm.htm. The site will list the 225 indicators, which can be easily sorted by performance measure, accreditation program, domains of performance, and general health concepts. The indicators, selected through an expert-based screening process, can be used to assess the performance of managed care organizations, integrated delivery networks, provider sponsored organizations, and other emerging delivery system forms. Indicators are divided into four broad categories and include 123 clinical performance measures, 20 health status measures, seven satisfaction measures, and 75 administrative/financial measures.

Hospital Sprinkler Warning
The Health Care Financing Administration (HCFA) recently issued a memo requesting that hospitals and nursing homes which care for Medicare beneficiaries check the brand of fire sprinkler installed at their facilities. According to HCFA officials, Underwriters Laboratory (UL) is investigating field reports indicating that higher than expected water pressure has been required to operate some "Omega" series sprinkler heads. The heads were manufactured by Central Sprinkler Company from 1982 through June 1996.

HCFA advises hospitals and nursing homes to check the manufacturer and series model of their sprinkler heads. If suspected heads are found, the facility should call Kerry Bell, UL, at (800) 758-1794 or Central Sprinkler Company at (800) 523-6512 for instructions on sending heads for testing. Facilities also are advised to document the response and corrective action taken to alleviate any problem. This information must be available for HCFA's Life Safety Code surveyor at its annual survey of the facility.

Medical Inflation On the Rise
Overall inflation fell by nearly half last year, but medical inflation was much more resistant to change. Consumer prices for medical goods and services rose 2.8% last year, down slightly from 1996's medical inflation rate of 3%, the U.S. Labor Department reported recently. By compassion, the overall inflation rate, known as the Consumer Price Index (CPI), fell to just 1.7% last year from 3.3% in 1996. Last year's inflation rate was the lowest since 1986's CPI of 1.1%.

Consumer prices for hospital services specifically also rose at a higher rate than general inflation last year, although hospital prices rose at a much slower rate than in 1996. Prices for hospital services rose 3.2% in 1997, compared with 4.1% in 1996, the government said.

The 4.1% increase in consumer prices for hospital care translated into a record $21.3 billion in profits for hospital in 1996. Prices for physician services, meanwhile, rose 2.7% last year compared with 3.0% in 1996.

Medical Devise Reuse Advisory
The American Hospital Association and the American Medical Group Association issued a joint quality advisory in December regarding the reuse of disposable medical devices. Reuse refers primarily to the cleaning, packaging, and sterilization for reuse of a single-use medical device after use by a patient. It also means sterilization of an unopened device (resterilization) and the packaging and sterilization of a device that has been opened, but not used on a patient (reprocessed).

The advisory cautions that the practice is being investigated by the Food and Drug Administration and that major media outlets are considering whether to do stories on it. While reuse of medical devices has been practiced by healthcare organizations for more than two decades, opponents say health risks outweigh benefits from lower costs and environmental concerns. Also, research has not conclusively proven reuse of certain medical devices to be safe and effective.

According to the advisory, unless an institution can demonstrate and document that patient safety and device effectiveness are not compromised by reusing a disposable medical device, reuse is not recommended. It also suggests that healthcare organizations' management should:

-- determine whether the organization is reusing disposable medical devices;
-- if applicable, discuss with the vice president of medical affairs, nurse executive, infection control personnel, materials management staff, central service personnel, outside contractors, or other appropriate personnel the protocol and processes in place concerning reuse of medical devices and on what basis the organization makes the decision to reuse;
-- understand fully the legal responsibilities and quality and public perception issues raised by this practice and be prepared to address them. Talk with clinical staff, legal counsel, risk managers, and communications professionals about the issue;
-- make sure decisions surrounding reuse are not made on a piecemeal basis, but are coordinated organization-wide;
-- educate all appropriate personnel on your organization's rules and processes on this issue;
-- and, develop clear guidelines for informing patients on use of these items.

Outpatient Surgery Loses Money
A new report by the Center for Healthcare Industry Performance Studies (CHIPS) shows that hospitals lose an average of $268 each time they perform an outpatient surgical procedure on a Medicare patient. Hospitals lost money on all 56 procedures examined in the CHIPS study, The Outpatient Procedures Resource Book.

CHIPS president William O. Cleverley, Ph.D., CPA, who co-authored the report along with Alden Solovy, executive editor of Hospitals and Health Networks, and Susan White, Ph.D., vice president of CHIPS, said the losses can be attributed to the way Medicare pays hospitals for the procedures. Cleverley says Medicare's policy of paying the lower of a hospital-specific amount -- actual costs or charges, whichever is less -- or an amount partially based on the hospital-specific amount and partially on the amount paid for the same procedure performed in a freestanding ambulatory surgery center (ASC), means a hospital can never make a profit on the surgical procedures. If the hospital's costs are higher than the freestanding ASC rate, then it will be paid the blended rate, which is less than its costs. At best, a hospital might break even.

Cleverley notes that investor-owned hospitals lose much less money on outpatient surgery. Investor-owned hospitals lost an average of $219 per procedure, compared with a loss of $283 among nonprofit government hospitals, $287 for church-sponsored nonprofits, and $282 among other nonprofit hospitals. Cost management appears to be the key to minimizing losses, and that comes through larger volumes. Cleverley explains that hospitals performing the largest numbers of each procedure kept their costs the lowest.

New Mammography Standards
New rules recently issued by the Food and Drug Administration (FDA) are designed to further improve the quality of mammography images and their interpretations. The rules were mandated by the Mammography Quality Standards Act (MQSA) passed by Congress in 1992.

The MQSA's regulations, which take effect April 28, 1998, dictate which organizations can accredit mammography clinics; establish new requirements for mammography equipment; and set training expectations for staff who work in mammography clinics. The MQSA initially required mammography clinics to be FDA-accredited every three years and inspected annually. The new regulations carry this quality control further by dictating which organizations and states may accredit mammography facilities.

The regulations also require that mammography facilities upgrade their equipment to meet standardized FDA equipment requirements. These requirements address tube-image assembly, image receptor sizes, beam limitation and light fields, magnification, focal spot selection, compression, technical factor selection and display, automatic exposure control, x-ray film, lightening, and film-masking devices. The FDA's new rule now:

-- mandates that physicians who interpret mammograms must have 60 hours of mammography training and technologists must perform an average of 200 mammograms every two years;
-- sets standards for imaging breast implants;
-- imposes more control over mobile mammography units;
-- requires each clinic to have a mechanism for consumer complaints;
-- mandates that, at a patient's request, clinics and practitioners share mammograms;
-- and, requires clinics to notify patients in writing of mammogram results.

For further information on the FDA's final mammography rule, contact Roger Burkhardt at the Center for Devices and Radiological Health at (301) 594-3332

Risk-Sharing Profits Reported
A recent report by Deloitte & Touche shows more than half the hospitals with risk-sharing arrangements ended up with surpluses at the end of last year, as did just under half the risk-sharing primary care physicians. Specialists lagged behind with under 40% reporting a surplus. The report was based on a survey of 260 large facilities engaged in risk sharing. Nearly 30% of the hospitals polled engaged in commercial risk sharing. When you tack on deals involving Medicare and Medicaid, risk sharing rose to 45%.

Mental Healthcare Access Problems
A survey by the Center for Studying Health System Change (CSHSC), Washington, DC, shows that many Americans lack access to mental health services even when their primary care physicians believe it is medically necessary. The findings -- based on responses from primary care physicians -- indicate that two-thirds of the reporting doctors can't obtain needed services for their patients. That compares with 36% who report the same level of difficulty obtaining non-emergency medical services.

According to CSHSC, several factors may make high quality mental health services more difficult for the primary care physicians to obtain for their patients. They include:

-- an overall shortage of mental health facilities and specialists;
-- a widespread growth of mental health managed care programs;
-- and, the failure of health insurance programs to adequately cover mental health benefits.

The report is sure to be embraced by proponents of mental health parity in insurance coverage, who call for equivalent insurance coverage for physical and mental health conditions. Opponents will argue that current limits must be maintained to prevent runaway costs among mental health providers.

Medicare HMOs to Pay Fees
In early 1998, Medicare health maintenance organizations (HMOs) were, for the first time, charged a fee to subsidize the Health Care Financing Administration's (HCFA) beneficiary information efforts related to the Medicare+Choice Program, the government Medicare managed care program. The December 2 Federal Register unveiled the proposal which would see Medicare HMOs paying nearly 0.5% of total Medicare payments to cover HCFA's campaign.

Under the Balanced Budget Act of 1997, these contractors must contribute their proportionate share of costs relating to beneficiary enrollment, dissemination of information, and certain counseling and assistance programs. HCFA says the information campaign will be designed to encourage growth in the Medicare+Choice Program, and that larger, more experienced plans should, therefore, be well positioned to take advantage of an expanding market. The federal appropriations bill for Fiscal Year 1998 permits federal officials to collect up to $95 million for the program.

Smoking Costs Tallied
According to the National Centers for Disease Control and Prevention (CDC), medical care spending for health conditions attributable to smoking more than doubled in recent years. In 1987, smoking led to diagnosis and treatment costs of $22 billion. By 1993, the figure had jumped to $50 billion. The CDC considers these numbers to be underestimated because they don't reflect medical care costs for diseases caused by the effects of second-hand smoke. The CDC estimates for spending by type of care are:

FCC Subsidy Aids Rural Providers
Although 20-30% of rural hospitals have tele-medicine programs, the high cost of long-distance phone lines deter many of them from utilizing the technology. Now, through the Telecommunications Act of 1996, public and nonprofit rural healthcare providers can apply for a subsidy that enables them to access telecommunication services at rates comparable to those paid for similar services in urban areas. The subsidy offered through the Federal Communications Commission (FCC) covers telephone and certain kinds of special telecommunication services, including Internet access.

The program's funding source is required contributions from interstate telecommunications carriers. Eligible applicants that do not have toll-free access to an Internet service provider can receive $180 per month or 30 hours of Internet service provider access per month. The FCC has created the Rural Health Care Corp., a quasi-public entity, to administer the fund. For more information about the program and to obtain an application form, contact the FCC at (888) 225-5322, or by accessing the FCC's Internet web site at http://www.fcc.gov/healthnet.

Giving Readers What They Want
Having a tough time coming up with new story ideas for your employee publication? A few years ago, the International Association of Business Communicators (IABC) surveyed its members, and here's what they said they wanted to read about in an employee publication (in order of interest):

1.The organization's short- and long-term plans.
2.Personnel policies and practices.
3.Improvements in productivity.
4.Job-related information.
5.Opportunities for job advancement.
6.The effect of external events on my job.
7.How the organization compares with its competitors.
8.News from various departments.
9.How my job fits into the organization.
10.How the organization uses profits.
11.Where the organization stands on local, regional, and national issues.
12.The organization's community involvement.
13.Personnel changes.
14.Financial results.
15.Employee stories.
16.Personal news.

Criticize Effectively
Here are 12 guidelines to remember the next time you have to tell someone that he or she has done something wrong:

1.Identify the behavior that you want to criticize. Direct your criticism at action, not the person.
2.Make criticisms specific. Not "You always miss deadlines." But: "You missed the March 15 deadline for your report."
3.Be sure the behavior you're criticizing can be changed. Foreign accents, baldness, and other things tangentially related to some business dealings cannot always be changed.
4.Use "I" and "we" to stress that you want to work out the problem together, rather than making threats.
5.Make sure the other person understands the reason for your criticism.
6.Don't belabor the point. Short and sweet; no lectures.
7.Offer incentives for changed behavior. Offer to help the person correct the problem.
8.Don' t set a tone of anger or sarcasm. Both are counterproductive.
9.Show the person you understand his or her feelings.
10.If you're putting your criticism in writing, cool off before writing the critical letter or memo. Be sure only the person it is intended for sees it.
11.Start off by saying something good.
12.At the end, reaffirm your support and confidence in the person.