Hospitals Struggle to Improve Patient Satisfaction

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Lillie Robinson came to Rowan Medical Center, Salisbury, North Carolina, for surgery on her left foot. She expected to be in and out in a day, returning weeks later for her surgeon to operate on the other foot.

But that’s not how things turned out. “When I got there I found out he was doing both,” she said. “My husband and I didn’t realize that until they started medicating me for the procedure.” Robinson signed a consent form and the operation went fine, but she was told she would be in the hospital far longer than she had expected.

“I wasn’t prepared for that,” she said.

Disappointing patients such as Robinson is a persistent problem for Rowan, a hospital with some lower levels of patient satisfaction in the country. In surveys sent to patients after they leave, Rowan’s patients were less likely than those at most hospitals to say they always received help promptly and that their pain was controlled well. Rowan’s patients said they would recommend the hospital far less often than patients do elsewhere.

Feedback from patients such as Robinson matters to Rowan and to hospitals across the country. Since Medicare began requiring hospitals to collect information about patient satisfaction and report it to the government in 2007, these patient surveys have grown in influence.  For the past three years, the federal government has considered survey results when setting pay levels for hospitals. Some private insurers do as well.

In April 2015, the government will begin boiling down the patient feedback into a five-star rating for hospitals. Federal officials say they hope that will make it easier for consumers to digest the information now available on Medicare’s Hospital Compare website. However, hospitals say judging them on a one-to-five scale is too simplistic.

Some Hospitals Improve As Others Stagnate 

Nationally, the hospital industry has improved in all the areas the surveys track, including how clean and quiet their rooms are and how well doctors and nurses communicate. But hundreds of hospitals have not made headway in boosting their ratings, federal records show.

For the most part, the organizations that are doing really wonderfully now were doing well five years ago, according to Press Ganey, a company that conducts the surveys for many hospitals. The high performers tend to continue to be the high performers and the low performers tend to be low performers.

Some hospitals have made great gains. The University of Missouri Health System, for example, created a live simulation center at its medical school in Columbia to help doctors learn to communicate better with patients. The simulations use paid actors. Instead of having to diagnose the patient, doctors must respond to nonmedical issues, such as a feuding teenager and mother or a patient angry that he was not given information about his condition quickly enough.

“My scenario was that I was late to the appointment and the patient’s husband was upset,” said a physician at Missouri’s University Hospital. In 2013, the most recent year that the government has provided data, 78 percent of patients at University Hospital said doctors always communicated well, a 10 percentage point jump from 2007. Other scores rose even more.

At Virginia Hospital Center in Arlington, executives credit improvements in patient satisfaction to their psychological screening methods in hiring and rigorous job reviews. Potential nurses and other staff must first pass a behavioral screening test and then be interviewed and endorsed by some of the staffers with whom they would be working. In the third element of the program, every six months, managers rate employee performance as high, medium or low. Low performers are told to improve or find work elsewhere.

“Those are the three most defining things we did as an organization,” said the hospital’s chief marketing officer. “Without that, it’s guaranteed we wouldn’t have had the successes.”

Rowan’s nurses now spend 70 percent of their time with patients, swinging by every hour. Even the president makes rounds once a day. The hospital has made lots of small improvements to provide a warmer environment, such as putting white poster boards in each room where nurses can list a few personal details about their patients.

“I can go in there and say ‘Oh, you have three dogs’ or ‘You have a great, great grandchild,’” said a nurse manager. “And a patient can talk about that for hours.”

The hospital staff pores over patient comments and surveys, passing around the good ones and tackling complaints. They are driven by what these patients say. Everything they do is based around how these patients come back with comments in the survey that say, this is working or this isn’t working.

Perceptions Are Sometimes Hard To Change 

Rowan executives fear scores may not be going up because patients still harbor bad memories from previous hospitalizations.

One patient said “It is fantastic from what it used to be if you want my opinion. “I’ve been both ways and the way it is now, it is great. No waiting and the doctors are all pleasant. I never thought I’d see it like this.” He said he would give the hospital top marks.

His daughter said that in the last visit she had to nag the nurses to get her dad his medication. This time, it has not been an issue. “It’s like a totally different hospital,” she said. “Did I come to Rowan Regional?”

Despite the unexpected operation on both feet, Robinson also said nurses have been attentive to her pain. “They do the best they can,” she said.

But “the best they can” is not good enough for Medicare. In determining how much to pay hospitals, the government only gives credit when patients says they “always” got the care they wanted during their stay, such as their pain was “always” well-controlled. If a patient says that level of care was “usually” provided, it does not count at all. Likewise, the surveys ask patients to rank their stays on a scale of 0 to 10; Medicare only pays attention to how many patients award the hospital a 9 or 10.

“Sometimes what we see and hear from our patients doesn’t show up on their surveys,” Rowan’s president said.

Another challenge for hospitals is that Medicare does not take into account the inexact nature of these ratings, which can be based on as few as 100 patients over a year. Medicare recommends a minimum of 300 surveys, but even those have imperfections that Medicare does not highlight when publishing ratings on Hospital Compare, or take into account when determining financial bonuses or penalties.

“Lillie Robinson said that they’d take great care of her as she recovered from surgery in the hospital. “They were very soothing, comforting, they weren’t condescending. It was a great experience, Lillie said.”

It’s Payback Time for Many Middle-Class Taxpayers

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Roberta and Curtis Campbell typically look forward to tax time. Most years, they receive a refund – a little extra cash to pay off credit card bills. But this year the California couple got a shock:  According to their tax preparer, they owe the IRS more than $6,000.

That’s the money the Campbells received from the federal government last year to make their Affordable Care Act health coverage more “affordable.” Roberta, unemployed when she signed up for the plan, got a job halfway through the year and Curtis found full-time work. The couple’s total yearly income became too high to qualify for federal subsidies. Now they have to pay back all the money.

“Oh my goodness, this is just not right,” said Roberta Campbell, who lives in the Sacramento suburb of Roseville. “This is supposed to be a health care insurance safety net and I am getting burned left and right by having used it.”

As tax day approaches, hundreds of thousands of families who enrolled in plans through the insurance marketplaces could be stuck with unexpected tax bills, according to researchers. Those payments could be as high as $11,000, although most would be several hundred dollars, one study found.

The result is frustration and confusion among some working and middle-class taxpayers, whom the Affordable Care Act was specifically intended to help. The repayment obligations could dissuade people from re-enrolling and provide more fuel to Republicans’ continuing push for a repeal of the law.

The problem is that many consumers didn’t realize that the subsidies were based on their total year-end income and couldn’t reliably project what would happen over the course of the year.

“How do you know if you are going to get that promotion?” Roberta said. “How do you know what your Christmas bonus is going to be?”

In addition, the government did not go out of its way to publicize the tax consequences of receiving too much in federal subsidies. It is not really something the administration focused on heavily. It’s not exactly popular.

The system was intended to ensure that people received the right amount in subsidies, no more or less than needed. But the means the government chose to reconcile the numbers was the tax system — notorious for its complexity well before the Affordable Care Act passed.

Enrollees who enrolled in The Affordable Care Act are now realizing that certain positive life changes – a pay raise, a marriage, a spouse’s new job – can turn out to be a liability at tax time.

H&R Block released a report in February 2015 saying that 52 percent of customers who received health coverage through the insurance marketplaces last year underestimated their income and now owe the government. They estimate that the average subsidy repayment amount is $530.

At the same time, about a third of those enrolled in marketplace coverage overestimated their income and are receiving money back – about $365 on average, the report said.

Under the Affordable Care Act, the federal government made subsidies available to people who earned up to 400 percent of the federal poverty level — about $47,000 for an individual and $63,000 for a couple.  For families who ended up making less than that, the federal government limits any repayments that might be due: The poorest consumers will have to repay no more than $300 and most others no more than $2,500. But the Campbells’ income last year exceeded the limit to receive federal help, so they have pay back the whole amount.

Roberta Campbell said she was only trying to do the right thing. Campbell, now 59, lost her job as a program director for the Arthritis Foundation in late 2012. She and her husband, who was working part-time as a merchandiser, downsized and moved into a smaller house.

They were left uninsured but were mindful of the federal mandate to be covered as of January 2014. So they signed up for a plan through California’s insurance marketplace, Covered California. The plan cost about $1,400 a month, but they were able to qualify for a monthly subsidy of about $1,000.

“We are rule followers,” she said. “We decided to get insurance because we were supposed to get insurance.”

They barely used the coverage. Roberta and Curtis each went to the doctor once for a check-up.  Then, about halfway through the year, Roberta got a job at UC Davis and became insured through the university. Curtis, who had been working part-time, got a full-time job for a magazine distribution company.

They notified Covered California, which Campbell said cancelled the insurance after 30 days. But with the new salaries, his pension from a previous career and a brief period of unemployment compensation, the couple’s year-end income totaled about $85,000, making them ineligible for any subsidies.

Their tax preparer told them they would have been better off not getting insurance at all and just paying the fine for being uninsured. In that case, the Campbells say their financial obligation would have been much smaller – about $850.

“The ironic thing is that we tried to pull ourselves up by our bootstraps,” Curtis Campbell said. “Now the IRS is going to penalize us. It’s frustrating.”

It’s not surprising that the projections people made about their income in 2014 in many cases were incorrect. The first open enrollment period started in October 2013, meaning that some enrollees based their estimates on what they earned in 2012.

Policy experts knew there would be a significant “churn” of people whose incomes change throughout the year and who would gain or lose their eligibility for subsidized coverage. But some experts said there was not enough understanding among consumers about how that could affect their taxes.

With tax season still underway, it’s not entirely clear how many people will have to repay the government for excess subsidies. But along with the recent H & R block estimates based on the firm’s customers, a UC Berkeley Labor Center study published in Health Affairs in 2013 suggested the numbers would not be not small.

Nationwide, 6.7 million people enrolled in marketplace exchanges through the Affordable Care Act in the first year. About 85 percent of people got federal help paying their insurance premiums.

Using California as a model, it’s estimated that even if everyone reported income changes to the insurance marketplace during the year, nearly 23 percent of consumers who were eligible for subsidies would have to pay the government back at least some of the amount received. About 9 percent of those receiving subsidies would have to pay the full amount. If no one reported changes, 38 percent would owe money.

The median repayment – if people reported income changes along the way — would be about $243 but some couples could owe more than $11,000, according to the research. The median amount due if people didn’t report the changes during the year would be $750.

The most important thing for people to do along the way is to report [income] changes so the subsidy amount is adjusted.

For those who must repay money, the IRS will allow payment in installments, even after the April 15 tax deadline. Interest will continue accruing, however, until the balance is paid.

Covered California spokesman Dana Howard said he understands paying back excess subsidies puts some in a difficult spot. But he said consumers who think their circumstances might change can decline the money or just take part of it.

Howard also said the subsidies were designed to give the working class people a leg up in affording health coverage. So when people get good jobs, he said, they don’t necessarily need the federal help to get insurance.

“When you get that really good fortune, that has to be shared back,” Howard said. “That is just how the Affordable Care Act law was written.”

$112 Billion in Life Insurance Lapses by Seniors

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The face value of life insurance policies lapsed, or surrendered back, to life companies annually by seniors over age 65 is enormous.

Based on 2008 data compiled by publicly available sources, more than 250,000 universal and variable universal policies with a face value of approximately $57 billion were lapsed by seniors over age 65. When term and whole life policies are included, the number of policies exceeds 1.1 million with a face value of $112 billion. If the data were available for 2014, the amount would be even greater.

This data illustrates that tens of thousands of seniors with billions of dollars of life insurance are forfeiting potential financial benefits from policies that are simply lapsed back to the insurance companies. Why is this so? It’s simply a lack of awareness.

For example, a 2010 survey prepared for the Insurance Studies Institute reported that more than half of seniors over the age of 65 are not familiar with the option to consider selling their life policy. Further, 90 percent of seniors who have let a policy lapse would have considered selling it if they had known a life settlement was an option.

In addition, a 2012 survey prepared for The Lifeline Program conducted by the Insurance Studies Institute indicated that 79 percent of clients feel lost about how a life settlement option works.

What about life insurance companies themselves? A 2010 Society of Actuaries survey indicated that 50 percent of life insurers don’t inform consumers about available life settlement options that should be considered when policies lapse. The most obvious reason is the enormous amount of lapses adds significant profits to their bottom lines.

The rationale, however, is that the absence of lapses would cause a significant increase in the cost of life insurance for future consumers.

The reality is that six states have passed some form of consumer disclosure legislation regarding notification of options available to lapsing a policy, including a life settlement. In the absence of insurance companies voluntarily informing their policyholders about these options, efforts to expand consumer disclosure legislation should be aggressively advanced in all states.

So, what does all this mean? There is a financial tragedy occurring in the senior population when billions of dollars of life insurance no longer needed or affordable are lapsed without knowledge of options that might be considered.

Would these options work for everybody? Obviously not. Would a life settlement work for everyone who considers lapsing a policy?  Realistically not. But to lapse a policy without knowledge about alternatives should be unacceptable.

Aside from any legal definition or inference of fiduciary responsibility, there is a moral obligation to inform and educate life insurance policy holders about the fact that a life insurance policy is a very important asset that should be managed within the context of all other assets. A study by Allianz Life Insurance reports that people age 44-75 fear running out of money (61 percent) more than dying (39 percent).

Collectively and cooperatively, the life insurance industry and the life settlement industry could bring a level of understanding and education to consumers about options that should be considered before lapsing their insurance policies.